Healthcare Provider Details

I. General information

NPI: 1063527497
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24160 NE ST RT 3
BELFAIR WA
98528-0457
US

IV. Provider business mailing address

PO BOX 457
BELFAIR WA
98528-0457
US

V. Phone/Fax

Practice location:
  • Phone: 360-275-6612
  • Fax: 360-275-6658
Mailing address:
  • Phone: 360-275-6612
  • Fax: 360-275-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT00002504
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00007051
License Number StateWA

VIII. Authorized Official

Name: MARK R DUTTON
Title or Position: OWNER/PT
Credential: PT
Phone: 360-275-6612