Provider Demographics
NPI:1093528879
Name:TAHOMA PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:TAHOMA PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:NOVOA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS, CMPT
Authorized Official - Phone:530-386-2452
Mailing Address - Street 1:1802 BLACK LAKE BLVD SW UNIT 104
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5665
Mailing Address - Country:US
Mailing Address - Phone:530-386-2452
Mailing Address - Fax:
Practice Address - Street 1:1802 BLACK LAKE BLVD SW UNIT 104
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5665
Practice Address - Country:US
Practice Address - Phone:530-386-2452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty