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Organization
MOUNTLAKE SPORTS & PHYSICAL THERAPY PS
Active
Organization
MOUNTLAKE SPORTS & PHYSICAL THERAPY PS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAMIE MALIJAN (CLINICAL MANAGER)
(425) 379-8120
Entity
Organization
Contact information
Practice address
9505 19TH AVE SE, 101, EVERETT, WA 98208-3853
(425) 379-8120
(425) 338-1789
Mailing address
9505 19TH AVE SE, 101, EVERETT, WA 98208-3853
(425) 379-8120
(425) 338-1789
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT00003917
WA
225100000X
Physical Therapist
PT60178380
WA
225700000X
Massage Therapist
MA00015079
WA
225700000X
Massage Therapist
MA00018299
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0151396
DEPARTMENT OF LABOR & INDUSTRIES
WA
05
—
7084650
—
WA
Enumeration date
02/22/2012
Last updated
02/22/2012
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