Healthcare Provider Details

I. General information

NPI: 1649284480
Provider Name (Legal Business Name): MARY LISA PRINCE MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY LISA FRADY MSPT

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 REDMOND WAY SUITE 300
REDMOND WA
98052-3862
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 425-883-9089
  • Fax: 425-869-1355
Mailing address:
  • Phone: 425-450-9474
  • Fax: 425-452-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00008397
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: