Provider Demographics
NPI:1649353053
Name:EAGLE ROCK PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:EAGLE ROCK PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:SONNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-689-4301
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:411 HOSPITAL WAY
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812
Mailing Address - Country:US
Mailing Address - Phone:509-689-4301
Mailing Address - Fax:509-689-4307
Practice Address - Street 1:411 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-4301
Practice Address - Fax:509-689-4307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006129225100000X
WAPT00003294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8323479Medicaid
WA8374126Medicaid
WV0206563OtherL & I BRIAN
WA0206566OtherL & I USR
8374126OtherUNITED MEDICAL
WA8374126Medicaid