Provider Demographics
NPI:1831279710
Name:TEDDER, RENEE T
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:T
Last Name:TEDDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 CORPORATE CENTER LOOP SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5952
Mailing Address - Country:US
Mailing Address - Phone:360-455-8155
Mailing Address - Fax:360-455-1655
Practice Address - Street 1:111 MARKET ST NE
Practice Address - Street 2:SUITE 108
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1008
Practice Address - Country:US
Practice Address - Phone:360-754-7085
Practice Address - Fax:360-754-3671
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1192TEOtherREGENCE BLUE SHIELD
WA710883456-98516-A003OtherTRICARE
WA4939TEOtherREGENCE BLUE SHIELD
WA710883456-98503-A009OtherTRICARE
WA6544TEOtherREGENCE BLUE SHIELD
WA710883456-98501-A010OtherTRICARE
WA8401820Medicaid
WA710883456-98512-A008OtherTRICARE
WA0219728OtherDEPT. OF LABOR & INDUSTRY
WA5691TEOtherREGENCE BLUE SHIELD
WA710883456-98502-A005OtherTRICARE
WA7242925OtherAETNA
WA8493TEOtherREGENCE BLUE SHIELD
WA8944149OtherL&I CRIME VICTIMS
WA710883456-98512-A008OtherTRICARE