Basic Information
| Provider Information | |||||||||
| NPI: | 1245265883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SOUND PHYSICAL & HAND THERAPY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTH SOUND PHYSICAL & HAND THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 6981 LITTLEROCK RD SW | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985127226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603527352 | ||||||||
| FaxNumber: | 3603527680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'KELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | SHANNON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253168046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH SOUND PHYSICAL & HAND THERAPY LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 3583413-01 | 01 | WA | OWCP | OTHER |