MEDICARE: MINDFUL MOVEMENT PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00005338	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0313855	OTHER	WA	WA LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1346684792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL MOVEMENT PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1570
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-4570
Country	:	US
Telephone Number	:	360-799-6921
Fax Number	:	360-799-6922

Provider Business Practice Location Address
First Line	:	3005 ALDERWOOD MALL PKWY
Second Line	:	SUITE 100
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-6920
Country	:	US
Telephone Number	:	206-979-1413
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN MAZZAFERRO-KNOWLES
Credential	:
Telephone Number	:	206-979-1413

Provider Enumeration Date	:	04/28/2013
Last Update Date	:	04/15/2020

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