MEDICARE: KATHRYN FONTANA DALE PT, OCS

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	PT00003228	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	216083	OTHER	WA	L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871655100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN FONTANA DALE PT, OCS

Provider Business Mailing Address
First Line	:	4040 ORCHARD ST W
Second Line	:	STE. 100
City	:	FIRCREST
State	:	WA
Zip	:	98466-6606
Country	:	US
Telephone Number	:	253-564-1560
Fax Number	:	253-564-4449

Provider Business Practice Location Address
First Line	:	451 SW SEDGWICK RD
Second Line	:	STE. 310
City	:	PORT ORCHARD
State	:	WA
Zip	:	98367-6447
Country	:	US
Telephone Number	:	360-874-8009
Fax Number	:	360-874-8010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	03/10/2014

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