Basic Information
| Provider Information | |||||||||
| NPI: | 1518031467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERTENS | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5210 CORPORATE CENTER CT SE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985035952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604558155 | ||||||||
| FaxNumber: | 3604551655 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 5TH ST SE STE 220 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983742106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534454258 | ||||||||
| FaxNumber: | 2534454724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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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 | OT00001454 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0264702 | 01 | WA | DEPT OF L&I | OTHER | 0319ME | 01 | WA | REGENCE | OTHER | 1518031467 | 01 | WA | DSHS | OTHER | 8368946 | 05 | WA | MEDICAID | LI0192217 | 01 | LABOR & INDUSTRIES | OTHER |