Basic Information
Provider Information | |||||||||
NPI: | 1437141124 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEAGRAVE | ||||||||
FirstName: | TAMMY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THACHUK | ||||||||
OtherFirstName: | TAMMY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 731269 | ||||||||
Address2: |   | ||||||||
City: | PUYALLUP | ||||||||
State: | WA | ||||||||
PostalCode: | 983730060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538402313 | ||||||||
FaxNumber: | 2538406340 | ||||||||
Practice Location | |||||||||
Address1: | 8910 184TH AVE E | ||||||||
Address2: |   | ||||||||
City: | BONNEY LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 983918531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538637510 | ||||||||
FaxNumber: | 2538635970 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00007933 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | TH5712 | 01 | WA | REGENCE BS | OTHER | 130029 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER | 8935156 | 01 | WA | CRIME VICTIME | OTHER | 8330516 | 05 | WA |   | MEDICAID |