Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | RPT-1023 | ID |
NPI | 1023260700 |
---|---|
Provider Name | Carey Ann Mack |
First Address | Colbert, WA 99005-0386 |
Second Address | Deer Park, WA 99006-9766 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/10/2008 |
Last Update Date | 14/10/2008 |