Healthcare Provider Details

I. General information

NPI: 1902155609
Provider Name (Legal Business Name): TERA TAGLIABUE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18404 102ND AVE NE SUITE A
BOTHELL WA
98011-3380
US

IV. Provider business mailing address

18404 102ND AVE NE SUITE A
BOTHELL WA
98011-3380
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-6079
  • Fax:
Mailing address:
  • Phone: 425-486-6079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 60280480
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 00019510
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: