Basic Information
| Provider Information | |||||||||
| NPI: | 1871586198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERTZIG | ||||||||
| FirstName: | SADA | ||||||||
| MiddleName: | K | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | OLSEN | ||||||||
| OtherFirstName: | SADA | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2170 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983900480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538402313 | ||||||||
| FaxNumber: | 2538406340 | ||||||||
| Practice Location | |||||||||
| Address1: | 32030 23RD AVE S | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539464852 | ||||||||
| FaxNumber: | 2539464862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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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 | PT00008879 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650024233 | 01 | WA | R/R MED KING COUNTY | OTHER | 5840HE | 01 | WA | REGENCE B/S | OTHER | 650024237 | 01 | WA | R/R MED PIERCE COUNTY | OTHER | 162111 | 01 | WA | DEPT OF L&I | OTHER | 8937359 | 01 | WA | CRIME VICTIMS | OTHER |