Provider Demographics
NPI:1013113786
Name:ETCHEBERRY, ELKE MONIKA (PTA)
Entity Type:Individual
Prefix:MS
First Name:ELKE
Middle Name:MONIKA
Last Name:ETCHEBERRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 THASOS AVE NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-4067
Mailing Address - Country:US
Mailing Address - Phone:360-613-0837
Mailing Address - Fax:360-613-0837
Practice Address - Street 1:140 S MARION AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-3639
Practice Address - Country:US
Practice Address - Phone:360-479-4747
Practice Address - Fax:360-478-6246
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111589Medicaid
WA4111589Medicaid
WA1780756932Medicare UPIN