Provider Demographics
NPI:1346684792
Name:MINDFUL MOVEMENT PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MINDFUL MOVEMENT PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZAFERRO-KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-979-1413
Mailing Address - Street 1:PO BOX 1570
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-4570
Mailing Address - Country:US
Mailing Address - Phone:360-799-6921
Mailing Address - Fax:360-799-6922
Practice Address - Street 1:3005 ALDERWOOD MALL PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6920
Practice Address - Country:US
Practice Address - Phone:206-979-1413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-28
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0313855OtherWA LABOR & INDUSTRIES