Provider Demographics
NPI:1578216339
Name:REZVANI, PEGAH (LMT)
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:REZVANI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23828 CARTER RD # B
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-9408
Mailing Address - Country:US
Mailing Address - Phone:805-312-5719
Mailing Address - Fax:
Practice Address - Street 1:8012 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-3601
Practice Address - Country:US
Practice Address - Phone:206-708-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61206118225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA