1649287582 NPI number — MRS. LORI CHRISTINE VAN DUSEN DPT

Table of content: MRS. LORI CHRISTINE VAN DUSEN DPT (NPI 1649287582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649287582 NPI number — MRS. LORI CHRISTINE VAN DUSEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DUSEN
Provider First Name:
LORI
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649287582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11711 NE 12TH STREET
Provider Second Line Business Mailing Address:
SUITE 3A
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-450-9474
Provider Business Mailing Address Fax Number:
425-635-9340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 5TH ST. SE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-445-4258
Provider Business Practice Location Address Fax Number:
253-445-4724
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00009546 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LI0189941 . This is a "LABOR & INDUSTRIES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8409393 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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