MEDICARE: KATIE BETTINA GRUBB P.T.

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	PT 00008246	WA

General Provider Information

NPI Number	:	1720134828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE BETTINA GRUBB P.T.

Provider Business Mailing Address
First Line	:	11711 NE 12TH ST
Second Line	:	STE. 3A
City	:	BELLEVUE
State	:	WA
Zip	:	98005-2461
Country	:	US
Telephone Number	:	425-214-0020
Fax Number	:	425-452-0667

Provider Business Practice Location Address
First Line	:	400 MAIN AVE S
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-8215
Country	:	US
Telephone Number	:	425-888-1156
Fax Number	:	425-888-6167

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	10/21/2011

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