Provider Demographics
NPI:1265433601
Name:DUTTON, MARK R (MPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:DUTTON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:21 NE ROMANCE HILL RD STE 101
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-9626
Mailing Address - Country:US
Mailing Address - Phone:360-275-6612
Mailing Address - Fax:360-275-6658
Practice Address - Street 1:21 NE ROMANCE HILL RD STE 101
Practice Address - Street 2:
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528-0457
Practice Address - Country:US
Practice Address - Phone:360-275-6612
Practice Address - Fax:360-275-6658
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00007051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA146767OtherL&I
WA193242800OtherOWCP
WA8336422Medicaid
WA8336422Medicaid
WA146767OtherL&I