Provider Demographics
NPI:1609130400
Name:LEWIS, CARLY KAY KISKA (DPT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:KAY KISKA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:KAY KISKA
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:209 KIRKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6503
Mailing Address - Country:US
Mailing Address - Phone:425-419-4363
Mailing Address - Fax:425-419-4969
Practice Address - Street 1:11400 SE 6TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6423
Practice Address - Country:US
Practice Address - Phone:425-576-8180
Practice Address - Fax:425-746-2002
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60277346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020740Medicaid
WAG8911222Medicare PIN