Provider Demographics
NPI:1225015753
Name:PAGOTELIS, REBECCA L (PT)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:L
Last Name:PAGOTELIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:HOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:23327 EAST APPLEWAY
Practice Address - Street 2:SUITE 106
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-5038
Practice Address - Country:US
Practice Address - Phone:509-891-2258
Practice Address - Fax:509-891-2094
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007987225100000X
AZ5138225100000X
IDRPT1677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8438046Medicaid
WA1225015753Medicaid
WA1225015753Medicaid
WA8438046Medicaid