Healthcare Provider Details

I. General information

NPI: 1740407816
Provider Name (Legal Business Name): LAKE SAMMAMISH PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 226TH PL SE STE 201
ISSAQUAH WA
98027-8969
US

IV. Provider business mailing address

11711 NE 12TH ST STE 3A
BELLEVUE WA
98005-2461
US

V. Phone/Fax

Practice location:
  • Phone: 425-391-5504
  • Fax: 425-391-3670
Mailing address:
  • Phone: 425-450-9474
  • Fax: 425-452-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateWA

VIII. Authorized Official

Name: DWAN DIAZ
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 425-450-9474