Provider Demographics
NPI:1275570574
Name:COLEMAN, DANIEL RAY (PT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAY
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9929 JOHNSON POINT RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-9339
Mailing Address - Country:US
Mailing Address - Phone:360-438-8042
Mailing Address - Fax:
Practice Address - Street 1:397 SUSSEX AVE E
Practice Address - Street 2:STE A
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9272
Practice Address - Country:US
Practice Address - Phone:360-264-6622
Practice Address - Fax:360-264-6624
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA121283OtherLABOR & INDUSTRIES
WACO5972OtherPREMERA BLUE CROSS
WATE5934OtherREGENCE
WA7091473Medicaid
WAGAB11205Medicare ID - Type Unspecified
WA121283OtherLABOR & INDUSTRIES