Provider Demographics
NPI:1245405224
Name:THERASPORT NORTHWEST, INC
Entity Type:Organization
Organization Name:THERASPORT NORTHWEST, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:509-484-0095
Mailing Address - Street 1:124 E ROWAN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1214
Mailing Address - Country:US
Mailing Address - Phone:509-484-0095
Mailing Address - Fax:509-484-0477
Practice Address - Street 1:124 E ROWAN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1214
Practice Address - Country:US
Practice Address - Phone:509-484-0095
Practice Address - Fax:509-484-0477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7100431Medicaid
WA17438OtherLABOR & INDUSTRIES
WA1104041458OtherINDIVIDUAL PROVIDER NPI
WAAB14875Medicare PIN
WAR79216Medicare UPIN