Basic Information
| Provider Information | |||||||||
| NPI: | 1972955201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVOTTI | ||||||||
| FirstName: | TESSA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAVOTTI | ||||||||
| OtherFirstName: | TESSA | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24060 SE KENT KANGLEY RD STE D100 | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980386801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903522 | ||||||||
| FaxNumber: | 4256909522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 60638338 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60638338 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2067441 | 05 | WA | MEDICAID |