Provider Demographics
NPI:1720055114
Name:MCKELVEY, MARILYN LEE (PT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:LEE
Last Name:MCKELVEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 OLYMPIC BLVD W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-1410
Mailing Address - Country:US
Mailing Address - Phone:253-564-0324
Mailing Address - Fax:253-756-7175
Practice Address - Street 1:2302 S UNION AVE
Practice Address - Street 2:SUITE B-10
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1300
Practice Address - Country:US
Practice Address - Phone:253-752-9303
Practice Address - Fax:253-756-7175
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7011869Medicaid
WA97699OtherL&I GROUP FACILITY PROV #
WA7011869Medicaid