Provider Demographics
NPI:1093478968
Name:BRIDGE THE GAP PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BRIDGE THE GAP PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, COACH
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SOUIK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CSCS, BRM
Authorized Official - Phone:920-917-0840
Mailing Address - Street 1:11811 NE 128TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7200
Mailing Address - Country:US
Mailing Address - Phone:920-917-0840
Mailing Address - Fax:
Practice Address - Street 1:11811 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7200
Practice Address - Country:US
Practice Address - Phone:920-917-0840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center