Provider Demographics
NPI:1265462147
Name:BLOOMQUIST, CLEO B (PT)
Entity Type:Individual
Prefix:
First Name:CLEO
Middle Name:B
Last Name:BLOOMQUIST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CLEO
Other - Middle Name:
Other - Last Name:BETTINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8510 186TH ST SW
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-5733
Mailing Address - Country:US
Mailing Address - Phone:425-778-2084
Mailing Address - Fax:
Practice Address - Street 1:16030 BOTHELL EVERETT HWY STE 140
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1273
Practice Address - Country:US
Practice Address - Phone:425-338-9005
Practice Address - Fax:426-337-0931
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000034052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WABL5114OtherREGENCE PIN#
WA8367559Medicaid