Provider Demographics
NPI:1598749996
Name:MACK, PATRICIA LOUISE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LOUISE
Last Name:MACK
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:LOUISE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 E HOLLAND AVE
Mailing Address - Street 2:STE 112
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1246
Mailing Address - Country:US
Mailing Address - Phone:509-838-2531
Mailing Address - Fax:509-755-6580
Practice Address - Street 1:505 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1426
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8333635Medicaid
WA8333635Medicaid