Basic Information
Provider Information | |||||||||
NPI: | 1477763464 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HIGHLINE PHYSICAL THERAPY GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HIGHLINE THERAPY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 31919 1ST AVE S | ||||||||
Address2: | SUITE 101 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980035236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538742998 | ||||||||
FaxNumber: | 2538743307 | ||||||||
Practice Location | |||||||||
Address1: | 13050 MILITARY RD S | ||||||||
Address2: |   | ||||||||
City: | TUKWILA | ||||||||
State: | WA | ||||||||
PostalCode: | 981683047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062483080 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2007 | ||||||||
LastUpdateDate: | 09/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIBBS | ||||||||
AuthorizedOfficialFirstName: | CLAUDINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMIN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 2538742998 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 7105653 | 05 | WA |   | MEDICAID |