Basic Information
| Provider Information | |||||||||
| NPI: | 1528371952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANABU | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | TAMI MEI LIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WONG | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | TAMI MEI LIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3925 159TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980526309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252160550 | ||||||||
| FaxNumber: | 4252160551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60161869 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1528371952 | 05 | WA | MEDICAID | P00964318 | 01 | WA | MEDICARE RAILROAD | OTHER | 0291642 | 01 | WA | DEPT. OF LABOR AND INDUSTRIES | OTHER |