Basic Information
| Provider Information | |||||||||
| NPI: | 1306942156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODBOLE | ||||||||
| FirstName: | MUKTI | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 132ND ST SE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980128999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253168046 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 NE PARK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980292642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256867405 | ||||||||
| FaxNumber: | 4253419041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT00003106 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0356877 | 01 | WA | L & I | OTHER | 0356816 | 01 | WA | L & I | OTHER |