Provider Demographics
NPI:1831252188
Name:QUEEN, MARISELLA A (PT)
Entity type:Individual
Prefix:
First Name:MARISELLA
Middle Name:A
Last Name:QUEEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:23925 225TH WAY SE
Mailing Address - Street 2:B
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5233
Mailing Address - Country:US
Mailing Address - Phone:425-433-0123
Mailing Address - Fax:425-433-0733
Practice Address - Street 1:301 S 320TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5200
Practice Address - Country:US
Practice Address - Phone:253-874-7000
Practice Address - Fax:253-874-7557
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPT00010316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1831252188Medicaid
WA1831252188Medicaid