1720055114 NPI number — MARILYN LEE MCKELVEY PT

Table of content: MARILYN LEE MCKELVEY PT (NPI 1720055114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720055114 NPI number — MARILYN LEE MCKELVEY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKELVEY
Provider First Name:
MARILYN
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1720055114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3602 OLYMPIC BLVD W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIVERSITY PLACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98466-1410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-564-0324
Provider Business Mailing Address Fax Number:
253-756-7175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2302 S UNION AVE
Provider Second Line Business Practice Location Address:
SUITE B-10
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-752-9303
Provider Business Practice Location Address Fax Number:
253-756-7175
Provider Enumeration Date:
03/03/2006

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:  PT00002092 , 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: 7011869 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97699 . This is a "L&I GROUP FACILITY PROV #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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