Provider Demographics
NPI:1881977148
Name:HARBOR PHYSICAL THERAPY AND WELLNESS CLINIC
Entity type:Organization
Organization Name:HARBOR PHYSICAL THERAPY AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-331-3969
Mailing Address - Street 1:PO BOX 958
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-0958
Mailing Address - Country:US
Mailing Address - Phone:360-331-3969
Mailing Address - Fax:360-331-0152
Practice Address - Street 1:5508 HARBOR AVE
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249
Practice Address - Country:US
Practice Address - Phone:360-331-3969
Practice Address - Fax:360-331-0152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603025614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty