Basic Information
| Provider Information | |||||||||
| NPI: | 1285270587 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOTEM LAKE PHYSICAL THERAPY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 118TH AVE SE STE 110 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980053875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4254520704 | ||||||||
| Practice Location | |||||||||
| Address1: | 12707 120TH AVE NE STE 203 | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980347500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256580296 | ||||||||
| FaxNumber: | 4259681454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | AYALA | ||||||||
| AuthorizedOfficialFirstName: | DWAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4254509474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.