Provider Demographics
NPI:1437571890
Name:ICENOGLE, JULIA (MOT, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JULIA
Middle Name:
Last Name:ICENOGLE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 132ND ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-316-8046
Mailing Address - Fax:425-338-9637
Practice Address - Street 1:7315 212TH ST SW STE 104
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-774-3226
Practice Address - Fax:425-670-1406
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 60399402225X00000X
OR312111225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist