Healthcare Provider Details

I. General information

NPI: 1295887792
Provider Name (Legal Business Name): ELIZABETH ANN REYNOLDS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANN KACINSKI

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21932 3RD DR SE
BOTHELL WA
98021-8270
US

IV. Provider business mailing address

21932 3RD DR SE
BOTHELL WA
98021-8270
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-8017
  • Fax: 425-486-8017
Mailing address:
  • Phone: 425-486-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00003792
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0217178
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerDEPT. OF LABOR & INDUSTRY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: