Basic Information
| Provider Information | |||||||||
| NPI: | 1548217631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SOUND PHYSICAL & HAND THERAPY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 132ND ST SE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980128999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 MARKET ST NE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985011008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607547085 | ||||||||
| FaxNumber: | 3607543671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | O'KELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | SHANNON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253168046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225XH1200X | 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 | 0164914 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 0164914 | 01 | WA | L&I CRIME VICTIMS | OTHER | DA0695 | 01 | WA | RAILROAD MEDICARE | OTHER | 3583413-00 | 01 | WA | OWCP | OTHER | 7108MA | 01 | WA | REGENCE BLUESHIELD GRP # | OTHER | 9054982 | 05 | WA | MEDICAID | 7683600 | 05 | WA | MEDICAID | 7112980 | 05 | WA | MEDICAID |