Provider Demographics
NPI:1205494051
Name:KENNISTON, MICHAEL STUART (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STUART
Last Name:KENNISTON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 114TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-7922
Mailing Address - Country:US
Mailing Address - Phone:916-759-3225
Mailing Address - Fax:
Practice Address - Street 1:800 10TH ST
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2131
Practice Address - Country:US
Practice Address - Phone:360-568-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60936491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist