Provider Demographics
NPI:1528196441
Name:COPPERSMITH, PENNY S (PT)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:S
Last Name:COPPERSMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5631
Mailing Address - Country:US
Mailing Address - Phone:206-789-2951
Mailing Address - Fax:
Practice Address - Street 1:5025 25TH AVE NE
Practice Address - Street 2:SUITE 201
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4151
Practice Address - Country:US
Practice Address - Phone:206-524-6702
Practice Address - Fax:206-524-6703
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5345COOtherREGENCE BLUE SHIELD
WA151617OtherLABOR & INDUSTRIES
WA5345COOtherREGENCE CARE
WA5345COOtherREGENCE CARE
WAAB32712Medicare ID - Type Unspecified
WAP00064205Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WAAB22718Medicare PIN