Basic Information
| Provider Information | |||||||||
| NPI: | 1649409830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIBIASE | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253379556 | ||||||||
| FaxNumber: | 4253579186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2009 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-653 | ID | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT 00006177 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0284484 | 01 | WA | L & I | OTHER | 0284518 | 01 | WA | L & I | OTHER | 0284489 | 01 | WA | L & I | OTHER | 0284524 | 01 | WA | L & I | OTHER |