Provider Demographics
NPI:1780666180
Name:KEITH, THOMAS (PT,)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KEITH
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 1:2312 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-4233
Mailing Address - Country:US
Mailing Address - Phone:360-687-7147
Mailing Address - Fax:
Practice Address - Street 1:2312 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4234
Practice Address - Country:US
Practice Address - Phone:360-687-7147
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB09908Medicare ID - Type Unspecified