Basic Information
Provider Information | |||||||||
NPI: | 1639536931 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEWITT | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRINKERHOFF | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 790 REMINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604404909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302962223 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 201 TAHOMA BLVD | ||||||||
Address2: | STE 207 | ||||||||
City: | YELM | ||||||||
State: | WA | ||||||||
PostalCode: | 985977735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604586400 | ||||||||
FaxNumber: | 3604586444 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2016 | ||||||||
LastUpdateDate: | 01/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | PT60715581 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.