Provider Demographics
NPI:1467945774
Name:OLYMPIC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:OLYMPIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVATT
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:865-200-3093
Mailing Address - Street 1:1750 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-5536
Mailing Address - Country:US
Mailing Address - Phone:865-200-3093
Mailing Address - Fax:
Practice Address - Street 1:1750 LINDA LN
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-5536
Practice Address - Country:US
Practice Address - Phone:865-200-3093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5424225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty