Basic Information
| Provider Information | |||||||||
| NPI: | 1699733840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALEY | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | PATRICIA | ||||||||
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| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GAUIN | ||||||||
| OtherFirstName: | CYNTHIA | ||||||||
| OtherMiddleName: | PATRICIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5775 SOUNDVIEW DR | ||||||||
| Address2: | B103 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538537956 | ||||||||
| FaxNumber: | 2538537958 | ||||||||
| Practice Location | |||||||||
| Address1: | 837 CALLAHAN DRIVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604798477 | ||||||||
| FaxNumber: | 3604798417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00009725 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8435489 | 05 | WA | MEDICAID |