Provider Demographics
NPI:1750378741
Name:MUDALIAR, SIVAN N (DPT)
Entity type:Individual
Prefix:
First Name:SIVAN
Middle Name:N
Last Name:MUDALIAR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:21806 103RD AVENUE CT E
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8115
Practice Address - Country:US
Practice Address - Phone:253-847-3700
Practice Address - Fax:253-847-9622
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist