Basic Information
| Provider Information | |||||||||
| NPI: | 1063508828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENT | ||||||||
| FirstName: | DARRYL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604239535 | ||||||||
| FaxNumber: | 3604149285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1560 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604239535 | ||||||||
| FaxNumber: | 3604149285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00006762 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0205347 | 01 | WA | LABOR & INDUSTRIES | OTHER |