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General NPI Number Information
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NPI Number | 1962556258
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Entity Type | Organization
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Legal Business Name | PACIFIC KIDS PEDIATRIC THERAPY, LLC
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 07/25/2008
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Provider Practice Location Address
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Address Line | 148 HARBORVIEW DRIVE
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City | BELLINGHAM
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State | WA
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Zip | 98229
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Country | US
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Telephone | 360-393-6210
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11009
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City | OLYMPIA
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State | WA
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Zip | 98508-1009
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Country | US
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Telephone | 360-393-6210
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | SHELLY BRASK
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Credential | OTRL
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Telephone | 360-393-6210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OT00002502
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License Number State | WA
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