Provider Demographics
NPI:1649284480
Name:PRINCE, MARY LISA (MSPT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LISA
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:LISA
Other - Last Name:FRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:#3A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:425-450-9474
Mailing Address - Fax:425-452-0704
Practice Address - Street 1:15600 REDMOND WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3862
Practice Address - Country:US
Practice Address - Phone:425-883-9089
Practice Address - Fax:425-869-1355
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7101058Medicaid
HI59767201Medicaid
WA0186224OtherLABOR & INDUSTRY
HIH102719Medicare PIN
HI59767201Medicaid
WAGAB38126Medicare PIN
HIH54201Medicare UPIN