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General NPI Number Information
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NPI Number | 1417093048
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Entity Type | Organization
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Legal Business Name | VALLEY PHYSICAL THERAPY PS
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 09/03/2014
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Provider Practice Location Address
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Address Line | 433 ELM STREET
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City | CLARKSTON
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State | WA
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Zip | 99403-2650
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Country | US
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Telephone | 509-758-5647
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Fax | 509-758-5648
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Provider Business Mailing Address
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Address Line | 433 ELM STREET
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City | CLARKSTON
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State | WA
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Zip | 99403-2650
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Country | US
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Telephone | 509-758-5647
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Fax | 509-758-5648
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | BROOKSIE K LARSON
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Credential | MPT
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Telephone | 509-758-5647
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT1411
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT00008466
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License Number State | WA
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