Provider Demographics
NPI:1578668075
Name:MALONE, KEVIN C (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:MALONE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27628 239TH PL SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6702
Mailing Address - Country:US
Mailing Address - Phone:360-886-5452
Mailing Address - Fax:
Practice Address - Street 1:23745 225TH WAY SE
Practice Address - Street 2:SUITE 215
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5294
Practice Address - Country:US
Practice Address - Phone:425-432-0821
Practice Address - Fax:888-259-5378
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2014-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8334476Medicaid
WA8803366Medicare PIN