Healthcare Provider Details

I. General information

NPI: 1548781131
Provider Name (Legal Business Name): CHARLEY LIU PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 11/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37624 SE FURY ST
SNOQUALMIE WA
98065-9680
US

IV. Provider business mailing address

550 OAKDALE AVE
GLENCOE IL
60022-2043
US

V. Phone/Fax

Practice location:
  • Phone: 425-292-0223
  • Fax:
Mailing address:
  • Phone: 847-501-0192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13873-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: