Provider Demographics
NPI:1235354903
Name:MIKLAVIC, CAROLYN O (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:O
Last Name:MIKLAVIC
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 KING ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-6262
Mailing Address - Country:US
Mailing Address - Phone:360-671-2900
Mailing Address - Fax:360-671-2828
Practice Address - Street 1:1400 KING ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-6262
Practice Address - Country:US
Practice Address - Phone:360-671-2900
Practice Address - Fax:360-671-2828
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8480733Medicaid
WA8480733Medicaid