Basic Information
| Provider Information | |||||||||
| NPI: | 1740407816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE SAMMAMISH PHYSICAL THERAPY, PLLC | ||||||||
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| OtherOrganizationName: | LAKE SAMMAMISH PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11711 NE 12TH ST STE 3A | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4254520704 | ||||||||
| Practice Location | |||||||||
| Address1: | 6520 226TH PL SE STE 201 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980278969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253915504 | ||||||||
| FaxNumber: | 4253913670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 11/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | DWAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4254509474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225100000X | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0039830 | 01 | WA | LABOR AND INDUSTRY | OTHER |