Basic Information
Provider Information | |||||||||
NPI: | 1548416001 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED REHABILITATION GROUP PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PACIFIC AVENUE HAND THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 3732 COLBY AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982014911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253742846 | ||||||||
FaxNumber: | 4253743272 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2008 | ||||||||
LastUpdateDate: | 11/03/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | O'KELLEY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | SHANNON | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
AuthorizedOfficialTelephone: | 4253579380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | INTEGRATED REHABILITATION GROUP PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 261Q00000X |   | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 379172614 | 01 | WA | OWCP | OTHER |