MEDICARE: MR. MICHAEL D TEATER PT, DPT, OCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT10121	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02062	OTHER		LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1508944554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL D TEATER PT, DPT, OCS

Provider Business Mailing Address
First Line	:	1905 SE 192ND AVE STE 109
Second Line	:
City	:	CAMAS
State	:	WA
Zip	:	98607-7415
Country	:	US
Telephone Number	:	360-210-5440
Fax Number	:	360-210-7731

Provider Business Practice Location Address
First Line	:	1905 SE 192ND AVE STE 109
Second Line	:
City	:	CAMAS
State	:	WA
Zip	:	98607-7415
Country	:	US
Telephone Number	:	360-210-5440
Fax Number	:	360-210-7731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	02/09/2026

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