Basic Information
| Provider Information | |||||||||
| NPI: | 1225055767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11711 NE 12TH ST | ||||||||
| Address2: | #3A | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4256359340 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 SE 28TH | ||||||||
| Address2: | #102 | ||||||||
| City: | MERCER ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980406005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062329045 | ||||||||
| FaxNumber: | 2062328871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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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 | PT00008195 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7060312 | 05 | WA | MEDICAID |