Healthcare Provider Details

I. General information

NPI: 1558509786
Provider Name (Legal Business Name): BONNEY LAKE PHYSICAL THERAPY AND HAND REHAB, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20910 STATE ROUTE 410 E
BONNEY LAKE WA
98391-6302
US

IV. Provider business mailing address

20910 STATE ROUTE 410 E
BONNEY LAKE WA
98391-6302
US

V. Phone/Fax

Practice location:
  • Phone: 253-862-2575
  • Fax: 253-862-2675
Mailing address:
  • Phone: 253-862-2575
  • Fax: 253-862-2675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT5418
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT2499
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT2499
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5418
License Number StateWA

VIII. Authorized Official

Name: MR. MICHAEL ANDREW EGBERT
Title or Position: PRESIDENT
Credential: PT
Phone: 253-862-2575