Basic Information
Provider Information | |||||||||
NPI: | 1700065729 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARK | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5210 CORPORATE CENTER LOOP SE | ||||||||
Address2: | SUITE D | ||||||||
City: | LACEY | ||||||||
State: | WA | ||||||||
PostalCode: | 985035952 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604558155 | ||||||||
FaxNumber: | 3604551655 | ||||||||
Practice Location | |||||||||
Address1: | 111 MARKET ST NE | ||||||||
Address2: | SUITE 108 | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985011008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607547085 | ||||||||
FaxNumber: | 3607543671 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2007 | ||||||||
LastUpdateDate: | 01/16/2009 | ||||||||
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 | PT23625 | FL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8515686 | 01 | WA | DSHS | OTHER | G8874834 | 01 | WA | MEDICARE | OTHER | 6275PA | 01 | WA | REGENCE | OTHER | 6572PA | 01 | WA | MEDICARE | OTHER | 3989PA | 01 | WA | REGENCE | OTHER | 4352PA | 01 | WA | REGENCE | OTHER | 237127 | 01 | WA | L&I | OTHER | 2877PA | 01 | WA | REGENCE | OTHER |