Basic Information
| Provider Information | |||||||||
| NPI: | 1144465659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LEE | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | MYERS | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13116 226TH ST E | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983387897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532087382 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2323 JENSEN ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608252541 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 60047356 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 314000000X | 8570 | OR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.