Basic Information
| Provider Information | |||||||||
| NPI: | 1669513743 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9514 4TH ST NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982581937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253972327 | ||||||||
| FaxNumber: | 4253770283 | ||||||||
| Practice Location | |||||||||
| Address1: | 9514 4TH ST NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982581937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253972327 | ||||||||
| FaxNumber: | 4253770283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PT00006593 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8340192 | 05 | WA | MEDICAID |