=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023301868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINETIC PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2011
-----------------------------------------------------
Last Update Date | 08/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4828 CALIFORNIA AVE SW
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98116-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-632-0163
-----------------------------------------------------
Fax | 206-932-2353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4828 CALIFORNIA AVE SW
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98116-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-632-0163
-----------------------------------------------------
Fax | 206-932-2353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST, OWNER
-----------------------------------------------------
Name | FAWN JENNIE COUSSENS
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 206-632-0163
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 602928536
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------