Basic Information
| Provider Information | |||||||||
| NPI: | 1902866700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANGIALOSI | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | MCCUNE | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 NE 45TH ST | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981054690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065457844 | ||||||||
| FaxNumber: | 2065457843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 09/04/2015 | ||||||||
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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 | PT00009565 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | G8899514 | 01 | WA | MEDICARE PTAN STRB | OTHER | G8894587 | 01 | WA | MEDICARE PTAN EOPT | OTHER |