Provider Demographics
NPI:1720692148
Name:LAU, KIMMY (PTA)
Entity Type:Individual
Prefix:
First Name:KIMMY
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 165TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-3027
Mailing Address - Country:US
Mailing Address - Phone:425-829-5501
Mailing Address - Fax:
Practice Address - Street 1:22659 PACIFIC HWY S STE 201
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-5155
Practice Address - Country:US
Practice Address - Phone:206-824-3668
Practice Address - Fax:206-971-1989
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160920732225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant