Provider Demographics
NPI:1114961414
Name:DRUSSEL, PHILLIP G (RPT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
Last Name:DRUSSEL
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 N COLUMBIA CENTER BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7800
Mailing Address - Country:US
Mailing Address - Phone:509-783-3444
Mailing Address - Fax:509-735-7711
Practice Address - Street 1:830 N COLUMBIA CENTER BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7800
Practice Address - Country:US
Practice Address - Phone:509-783-3444
Practice Address - Fax:509-735-7711
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA47928OtherDEPT OF LABOR & INDUSTRIE
WA8333189Medicaid
WAAB33091Medicare ID - Type Unspecified