Healthcare Provider Details

I. General information

NPI: 1447196449
Provider Name (Legal Business Name): MOUNTAINSIDE PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38110 236TH AVE SE
ENUMCLAW WA
98022-5802
US

IV. Provider business mailing address

38110 236TH AVE SE
ENUMCLAW WA
98022-5802
US

V. Phone/Fax

Practice location:
  • Phone: 425-358-1587
  • Fax:
Mailing address:
  • Phone: 425-358-1587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KAYLEE VINSON
Title or Position: OWNER
Credential:
Phone: 425-358-1587