Basic Information
Provider Information | |||||||||
NPI: | 1649287582 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN DUSEN | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | CHRISTINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11711 NE 12TH STREET | ||||||||
Address2: | SUITE 3A | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 98005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254509474 | ||||||||
FaxNumber: | 4256359340 | ||||||||
Practice Location | |||||||||
Address1: | 3801 5TH ST. SE | ||||||||
Address2: | SUITE 220 | ||||||||
City: | PUYALLUP | ||||||||
State: | WA | ||||||||
PostalCode: | 98374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534454258 | ||||||||
FaxNumber: | 2534454724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 06/25/2012 | ||||||||
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 | PT00009546 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | LI0189941 | 01 |   | LABOR & INDUSTRIES | OTHER | 8409393 | 05 | WA |   | MEDICAID |