Provider Demographics
NPI:1477068641
Name:DIVERSIFIED PAIN & MOVEMENT THERAPY
Entity Type:Organization
Organization Name:DIVERSIFIED PAIN & MOVEMENT THERAPY
Other - Org Name:DIVERSIFIED MOVEMENT THERAPY MEDITOUCH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSEVEAR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:425-531-9886
Mailing Address - Street 1:875 140TH AVE NE STE 103
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3400
Mailing Address - Country:US
Mailing Address - Phone:425-531-9886
Mailing Address - Fax:253-345-5129
Practice Address - Street 1:875 140TH AVE NE STE 103
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005
Practice Address - Country:US
Practice Address - Phone:425-531-9886
Practice Address - Fax:253-345-5129
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSIFIED PAIN & MOVEMENT THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-08
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
IDOT553261QM1300X
IN31001125A261QM1300X
WAOT60067862225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2098601Medicaid