Basic Information
| Provider Information | |||||||||
| NPI: | 1184976177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTHELOTE | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | BRITTANY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6704 NE 181ST ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980284890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254194363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6704 NE 181ST ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980284890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254194363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60268057 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0302382 | 01 | WA | L&I | OTHER | 1184976177 | 05 | WA | MEDICAID |