Basic Information
| Provider Information | |||||||||
| NPI: | 1871655100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALE | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | FONTANA | ||||||||
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| Credential: | PT, OCS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FONTANA | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | MARY FRANCIS | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4040 ORCHARD ST W | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | FIRCREST | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984666606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535641560 | ||||||||
| FaxNumber: | 2535644449 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 SW SEDGWICK RD | ||||||||
| Address2: | STE. 310 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983676447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608748009 | ||||||||
| FaxNumber: | 3608748010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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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 | PT00003228 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 216083 | 01 | WA | L&I | OTHER | 8341794 | 05 | WA | MEDICAID |