Provider Demographics
NPI:1205992807
Name:RACICOT, MIMI M (PT)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:M
Last Name:RACICOT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:RACICOT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3400 CALIFORNIA AVE SW
Mailing Address - Street 2:STE 100
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116
Mailing Address - Country:US
Mailing Address - Phone:206-320-5510
Mailing Address - Fax:206-320-5522
Practice Address - Street 1:3400 CALIFORNIA AVE SW
Practice Address - Street 2:STE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116
Practice Address - Country:US
Practice Address - Phone:206-320-5510
Practice Address - Fax:206-320-5522
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0195785OtherLABOR AND INDUSTRIES
WA8422222Medicaid
WA8853422Medicare ID - Type Unspecified
WA8422222Medicaid