Provider Demographics
NPI:1205233327
Name:BUCHOLZ, KATIE ELISABETH (PT, DPT, OCS)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ELISABETH
Last Name:BUCHOLZ
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 ORCHARD ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6610
Mailing Address - Country:US
Mailing Address - Phone:253-564-1560
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:732 LEBO BLVD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3325
Practice Address - Country:US
Practice Address - Phone:360-479-8477
Practice Address - Fax:360-479-8417
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA419592251X0800X, 225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1205233327OtherNPI
CACA199746Medicare PIN