Basic Information
| Provider Information | |||||||||
| NPI: | 1649639709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALCZYK | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOERES | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3901 CAPITAL MALL DR SW | ||||||||
| Address2: | SUITE D | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985028654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607096221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3901 CAPITAL MALL DR SW | ||||||||
| Address2: | SUITE D | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985028654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607096221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2016 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 60620609 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.