Provider Demographics
NPI:1588806848
Name:LAKE FOREST PARK PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:LAKE FOREST PARK PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:NAMIKO
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:LPTA
Authorized Official - Phone:206-979-8248
Mailing Address - Street 1:20011 BALLINGER WAY NE
Mailing Address - Street 2:STE C100
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1286
Mailing Address - Country:US
Mailing Address - Phone:206-367-6069
Mailing Address - Fax:206-367-6319
Practice Address - Street 1:20011 BALLINGER WAY NE
Practice Address - Street 2:STE C100
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1286
Practice Address - Country:US
Practice Address - Phone:206-367-6069
Practice Address - Fax:206-367-6319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002011261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8371353Medicaid