Provider Demographics
NPI:1922178201
Name:IMPACT PHYSICAL THERAPY, P.S.
Entity Type:Organization
Organization Name:IMPACT PHYSICAL THERAPY, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-IMPACT PHYSICAL THERAPY, P.S.
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-778-2325
Mailing Address - Street 1:6101 200TH ST SW STE 208
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6077
Mailing Address - Country:US
Mailing Address - Phone:425-778-2325
Mailing Address - Fax:425-778-7692
Practice Address - Street 1:6101 200TH ST SW STE 208
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6077
Practice Address - Country:US
Practice Address - Phone:425-778-2325
Practice Address - Fax:425-778-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008381225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA173816OtherL&I
WA1905229OtherFIRST HEALTH
WA=========OtherAETNA
WA173816OtherL&I
WA=========OtherUNIFORM
WA=========OtherUNITED HEALTH CARE
WA=========98020A001OtherTRICARE
WA=========OtherFIRST CHOICE
WA=========OtherPREMERA
WA=========OtherFIRST CHOICE MANAGED CARE
WA=========98020A001OtherTRICARE