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General NPI Number Information
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NPI Number | 1558194423
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Entity Type | Individual
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Provider Name | ISRAEL ELLERBROCK PTA
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Gender | Male
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Dates
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Enumeration Date | 08/24/2024
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Last Update Date | 08/24/2024
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Provider Practice Location Address
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Address Line | 615 LILLY RD NE STE 240
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City | OLYMPIA
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State | WA
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Zip | 98506-5117
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Country | US
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Telephone | 360-413-3850
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Fax |
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Provider Business Mailing Address
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Address Line | 2314 COOPER CREST ST NW
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City | OLYMPIA
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State | WA
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Zip | 98502-4032
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Country | US
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Telephone | 831-207-0828
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | P160835239
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License Number State | WA
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