Provider Demographics
NPI:1649639709
Name:WALCZYK, KATIE JEAN (PT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JEAN
Last Name:WALCZYK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JEAN
Other - Last Name:GOERES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3901 CAPITAL MALL DR SW
Mailing Address - Street 2:SUITE D
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8654
Mailing Address - Country:US
Mailing Address - Phone:360-709-6221
Mailing Address - Fax:
Practice Address - Street 1:3901 CAPITAL MALL DR SW
Practice Address - Street 2:SUITE D
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8654
Practice Address - Country:US
Practice Address - Phone:360-709-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60620609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist