Basic Information
| Provider Information | |||||||||
| NPI: | 1649284480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LISA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRADY | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | LISA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11711 NE 12TH ST | ||||||||
| Address2: | #3A | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4254520704 | ||||||||
| Practice Location | |||||||||
| Address1: | 15600 REDMOND WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980523862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258839089 | ||||||||
| FaxNumber: | 4258691355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008397 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7101058 | 05 | WA | MEDICAID | 59767201 | 05 | HI | MEDICAID | 0186224 | 01 | WA | LABOR & INDUSTRY | OTHER |