Healthcare Provider Details

I. General information

NPI: 1154369833
Provider Name (Legal Business Name): INTEGRATED REHABILITATION GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 132ND ST SE SUITE 101
MILL CREEK WA
98012-8999
US

IV. Provider business mailing address

4220 132ND ST SE SUITE101
MILL CREEK WA
98012-8999
US

V. Phone/Fax

Practice location:
  • Phone: 425-316-8046
  • Fax: 425-659-7449
Mailing address:
  • Phone: 425-316-8046
  • Fax: 425-338-9637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SHANNON O'KELLEY
Title or Position: PRESIDENT/OWNER
Credential: MPT
Phone: 425-316-8046