Provider Demographics
NPI:1407115330
Name:ELEVATE PHYSICAL THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:ELEVATE PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:425-458-2046
Mailing Address - Street 1:23860 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-3604
Mailing Address - Country:US
Mailing Address - Phone:425-458-2046
Mailing Address - Fax:425-458-2047
Practice Address - Street 1:23880 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-3604
Practice Address - Country:US
Practice Address - Phone:425-458-2046
Practice Address - Fax:425-458-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-12
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603176468261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8880643Medicare PIN