Basic Information
| Provider Information | |||||||||
| NPI: | 1871698050 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GODFREY | ||||||||
| FirstName: | RENA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S CEDAR ST STE B1 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532726910 | ||||||||
| FaxNumber: | 2533834218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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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 | PT00005367 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | GO9746 | 01 | VA | PREMERA BLUE CROSS | OTHER | P00286357 | 01 | WA | RAILROAD MEDICARE | OTHER | GO9746 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8341430 | 05 | WA | MEDICAID | 0197667 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | 0296931 | 01 | WA | L & I | OTHER |