Healthcare Provider Details

I. General information

NPI: 1265701395
Provider Name (Legal Business Name): LIBERTY PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 12TH AVE SUITE 101
SEATTLE WA
98122-2438
US

IV. Provider business mailing address

9000 SE 45TH ST
MERCER ISLAND WA
98040-4144
US

V. Phone/Fax

Practice location:
  • Phone: 206-860-3746
  • Fax:
Mailing address:
  • Phone: 206-778-6405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number00002906
License Number StateWA

VIII. Authorized Official

Name: DR. KIM BENNETT
Title or Position: PHYSICAL THERAPIST/OWNER MANAGER
Credential: PT PHD
Phone: 206-778-6405