Provider Demographics
NPI:1811565740
Name:REARDON, LUKE WILLIAM
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:WILLIAM
Last Name:REARDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 N COLLEGE AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1048
Mailing Address - Country:US
Mailing Address - Phone:509-876-8900
Mailing Address - Fax:509-593-4006
Practice Address - Street 1:56 N COLLEGE AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1048
Practice Address - Country:US
Practice Address - Phone:509-876-8900
Practice Address - Fax:509-593-4006
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61177063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist