Basic Information
| Provider Information | |||||||||
| NPI: | 1588601850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEDDER | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1018 CAPITOL WAY S | ||||||||
| Address2: | STE 300 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985011212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604134200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2555 MARVIN RD NE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985163138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604134220 | ||||||||
| FaxNumber: | 3604134225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00009225 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4194TE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 710883456-98501-A007 | 01 | WA | TRICARE | OTHER | 8382988 | 05 | WA | MEDICAID | 0195457 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 8905065 | 01 | WA | L&I CRIME VICTIMS | OTHER | 710883456-98512-A006 | 01 | WA | TRICARE | OTHER | 0195458 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 7883504 | 01 | WA | AETNA | OTHER | 911745305-98501-A002 | 01 | WA | TRICARE | OTHER | 3186TE | 01 | WA | REGENCE BLUE SHIELD | OTHER |