Provider Demographics
NPI:1770164964
Name:LIFE SPAN OCCUPATIONAL THERAPY LLC
Entity type:Organization
Organization Name:LIFE SPAN OCCUPATIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:425-395-6006
Mailing Address - Street 1:PO BOX 4314
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-4020
Mailing Address - Country:US
Mailing Address - Phone:425-395-6006
Mailing Address - Fax:
Practice Address - Street 1:1240 RUDDELL RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5747
Practice Address - Country:US
Practice Address - Phone:425-395-6006
Practice Address - Fax:360-918-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT60105178OtherDEPT OF HEALTH