Provider Demographics
NPI:1649800608
Name:PNW HOME FOR LIFE PLLC
Entity type:Organization
Organization Name:PNW HOME FOR LIFE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:360-770-1752
Mailing Address - Street 1:4815 SHARPE RD
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-8403
Mailing Address - Country:US
Mailing Address - Phone:360-770-1752
Mailing Address - Fax:
Practice Address - Street 1:4815 SHARPE RD
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-8403
Practice Address - Country:US
Practice Address - Phone:360-770-1752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental ModificationGroup - Single Specialty