Provider Demographics
NPI:1407063340
Name:HANSEN, THOMAS HAROLD (PT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HAROLD
Last Name:HANSEN
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 1:14022 SE 158TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-7812
Mailing Address - Country:US
Mailing Address - Phone:425-277-1394
Mailing Address - Fax:
Practice Address - Street 1:24216 WITTE RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6827
Practice Address - Country:US
Practice Address - Phone:425-413-3583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000066172251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8344194Medicaid