Healthcare Provider Details

I. General information

NPI: 1881147163
Provider Name (Legal Business Name): MALLORY OLMSTEAD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 3RD AVE STE 104
SEATTLE WA
98101-3008
US

IV. Provider business mailing address

1218 3RD AVE STE 104
SEATTLE WA
98101-3008
US

V. Phone/Fax

Practice location:
  • Phone: 206-447-2220
  • Fax: 206-447-2228
Mailing address:
  • Phone: 206-447-2220
  • Fax: 206-447-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP1 60639331
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: