Healthcare Provider Details

I. General information

NPI: 1558194423
Provider Name (Legal Business Name): ISRAEL ELLERBROCK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2024
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LILLY RD NE STE 240
OLYMPIA WA
98506-5117
US

IV. Provider business mailing address

2314 COOPER CREST ST NW
OLYMPIA WA
98502-4032
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-3850
  • Fax:
Mailing address:
  • Phone: 831-207-0828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP160835239
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: