Healthcare Provider Details

I. General information

NPI: 1194417063
Provider Name (Legal Business Name): NORHANA MALAWI IMAM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 11/04/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 3RD AVE
LONGVIEW WA
98632-3229
US

IV. Provider business mailing address

391 HILLSDALE DR
WOODLAND WA
98674-8122
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-9535
  • Fax:
Mailing address:
  • Phone: 971-433-9160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number61450689
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012115
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: