Healthcare Provider Details

I. General information

NPI: 1679754170
Provider Name (Legal Business Name): MELISSA RACOUILLAT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14028 SE PETROVITSKY RD
RENTON WA
98058-8933
US

IV. Provider business mailing address

PO BOX 9955
SEATTLE WA
98109-0955
US

V. Phone/Fax

Practice location:
  • Phone: 425-272-0252
  • Fax:
Mailing address:
  • Phone: 415-680-0247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 34048
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60383867
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: