Basic Information
Provider Information | |||||||||
NPI: | 1831279710 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TEDDER | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
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: | 10/16/2006 | ||||||||
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 | PT00009010 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1192TE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 710883456-98516-A003 | 01 | WA | TRICARE | OTHER | 4939TE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 710883456-98503-A009 | 01 | WA | TRICARE | OTHER | 6544TE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 710883456-98501-A010 | 01 | WA | TRICARE | OTHER | 8401820 | 05 | WA |   | MEDICAID | 710883456-98512-A008 | 01 | WA | TRICARE | OTHER | 0219728 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 5691TE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 710883456-98502-A005 | 01 | WA | TRICARE | OTHER | 7242925 | 01 | WA | AETNA | OTHER | 8493TE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8944149 | 01 | WA | L&I CRIME VICTIMS | OTHER |