Basic Information
| Provider Information | |||||||||
| NPI: | 1902060197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | BIRD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | G.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BIRD | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253379556 | ||||||||
| FaxNumber: | 4253579186 | ||||||||
| Practice Location | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253379556 | ||||||||
| FaxNumber: | 4253579186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 09/06/2011 | ||||||||
| 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 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8948510 | 01 | WA | L&I CRIME | OTHER | 0273751 | 01 | WA | DEPT OF L&I | OTHER | 1020BI | 01 | WA | REGENCE | OTHER | P00738996 | 01 | WA | RAILROAD MEDICARE IRG | OTHER | 1170BI | 01 | WA | REGENCE | OTHER | 2060BI | 01 | WA | REGENCE | OTHER | 8522666 | 01 | WA | DSHS | OTHER | P00664566 | 01 | WA | RAILROAD MEDICARE | OTHER | 239386 | 01 | WA | L&I | OTHER | 4030BI | 01 | WA | REGENCE | OTHER | 6097BI | 01 | WA | REGENCE | OTHER | 239347 | 01 | WA | L&I | OTHER | 2588BI | 01 | WA | REGENCE | OTHER | 0157BI | 01 | WA | REGENCE | OTHER | 5029BI | 01 | WA | REGENCE | OTHER | 8948544 | 01 | WA | L&I CRIME | OTHER |