Basic Information
| Provider Information | |||||||||
| NPI: | 1679754170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACOUILLAT | ||||||||
| FirstName: | MELISSA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9955 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981090955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156800247 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14028 SE PETROVITSKY RD | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980588933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252720252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 34048 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60383867 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1679754170 | 05 | WA | MEDICAID | 328947 | 01 | WA | WA L&I | OTHER | 328948 | 01 | WA | WA L&I | OTHER |