Basic Information
| Provider Information | |||||||||
| NPI: | 1689050049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTA | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | TEAL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DODDS | ||||||||
| OtherFirstName: | HANNAH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8750 GREENWOOD AVE N | ||||||||
| Address2: | S1 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067825789 | ||||||||
| FaxNumber: | 2067825794 | ||||||||
| Practice Location | |||||||||
| Address1: | 3290 NE 65TH ST | ||||||||
| Address2: | UNIT 101 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063882549 | ||||||||
| FaxNumber: | 2068294352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
| 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 | PT60559764 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1689050049 | 05 | WA | MEDICAID | 0349709 | 01 | WA | WA L&I | OTHER |