Provider Demographics
NPI:1417271271
Name:CLEMMONS, LAURA FLAHERTY (DPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:FLAHERTY
Last Name:CLEMMONS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21009 76TH AVE W
Mailing Address - Street 2:AXIS PHYSICAL THERAPY INC
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7126
Mailing Address - Country:US
Mailing Address - Phone:425-672-2910
Mailing Address - Fax:425-778-1872
Practice Address - Street 1:21009 76TH AVE W
Practice Address - Street 2:AXIS PHYSICAL THERAPY INC
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7126
Practice Address - Country:US
Practice Address - Phone:425-672-2910
Practice Address - Fax:425-778-1872
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60141891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417271271Medicaid
WA1417271271Medicaid