Healthcare Provider Details

I. General information

NPI: 1295919181
Provider Name (Legal Business Name): NORTHLAKE REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18600 WOODINVILLE SNOHOMISH RD NE
WOODINVILLE WA
98072-8531
US

IV. Provider business mailing address

18323 BOTHELL EVERETT HWY STE 220
BOTHELL WA
98012-5246
US

V. Phone/Fax

Practice location:
  • Phone: 425-488-6640
  • Fax: 425-488-5424
Mailing address:
  • Phone: 425-806-5700
  • Fax: 425-806-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. TARA L URBAN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 425-806-5721