Healthcare Provider Details

I. General information

NPI: 1770020992
Provider Name (Legal Business Name): PEDIATRIC REHABILITATION ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 COOKS HILL RD
CENTRALIA WA
98531-9073
US

IV. Provider business mailing address

117 E LOUISA ST #370
SEATTLE WA
98102-3203
US

V. Phone/Fax

Practice location:
  • Phone: 253-268-0720
  • Fax:
Mailing address:
  • Phone: 206-329-1468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD60570885
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberMD60570885
License Number StateWA

VIII. Authorized Official

Name: SUSAN QUIGLEY
Title or Position: MD/OWNER
Credential: MD
Phone: 206-482-0103