Provider Demographics
NPI:1326029661
Name:MCRAE, GEORGIA ANN (PT)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:ANN
Last Name:MCRAE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GEORGIA
Other - Middle Name:ANN
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4606 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE C
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4200
Mailing Address - Country:US
Mailing Address - Phone:253-565-3551
Mailing Address - Fax:253-565-4535
Practice Address - Street 1:4606 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE C
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4200
Practice Address - Country:US
Practice Address - Phone:253-565-3551
Practice Address - Fax:253-565-4535
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7041437Medicaid
WA7041437Medicaid
WAG001061601Medicare PIN