Provider Demographics
NPI:1891807582
Name:WASZAK, MIRA (OT)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:WASZAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 KIRKLAND WAY
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6219
Mailing Address - Country:US
Mailing Address - Phone:425-827-7031
Mailing Address - Fax:425-827-0102
Practice Address - Street 1:515 KIRKLAND WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6219
Practice Address - Country:US
Practice Address - Phone:425-827-7031
Practice Address - Fax:425-827-0102
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT3335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50-6570Medicare ID - Type UnspecifiedMEDICARE