Basic Information
Provider Information | |||||||||
NPI: | 1548228067 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LABARRE | ||||||||
FirstName: | TANYA | ||||||||
MiddleName: | MARIE-HELENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARDILLO | ||||||||
OtherFirstName: | TANYA | ||||||||
OtherMiddleName: | MARIE-HELENE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4040 ORCHARD ST W | ||||||||
Address2: | SUITE 100 | ||||||||
City: | FIRCREST | ||||||||
State: | WA | ||||||||
PostalCode: | 984666606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535641560 | ||||||||
FaxNumber: | 2535644449 | ||||||||
Practice Location | |||||||||
Address1: | 4060 WHEATON WAY | ||||||||
Address2: | SUITE C | ||||||||
City: | BREMERTON | ||||||||
State: | WA | ||||||||
PostalCode: | 983103500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604798477 | ||||||||
FaxNumber: | 3604798417 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 11/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00007663 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8341992 | 05 | WA |   | MEDICAID |