Provider Demographics
NPI:1154302081
Name:POULOS, MICHAEL JAMES (OTR L CHT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:POULOS
Suffix:
Gender:M
Credentials:OTR L CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-1557
Mailing Address - Country:US
Mailing Address - Phone:360-676-4263
Mailing Address - Fax:660-671-3366
Practice Address - Street 1:1611 BROADWAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-3039
Practice Address - Country:US
Practice Address - Phone:360-676-4263
Practice Address - Fax:360-671-3366
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5692P0OtherREGENCE BLUE SHIELD
WA0156374OtherLABOR AND INDUSTRIES
WA8935446OtherCRIME VICTIMS LABOR AND I
1960076OtherFIRST HEALTH
WA7682388Medicaid
WAAB26864Medicare ID - Type Unspecified