Provider Demographics
NPI:1104048453
Name:CARBAUGH, DARLA SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:DARLA
Middle Name:SUE
Last Name:CARBAUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:DARLA
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356-0145
Mailing Address - Country:US
Mailing Address - Phone:360-496-0087
Mailing Address - Fax:360-496-0078
Practice Address - Street 1:250 C WESTLAKE AVENUE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356-0145
Practice Address - Country:US
Practice Address - Phone:360-496-0087
Practice Address - Fax:360-496-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7127327Medicaid
WA0192531OtherLABOR & INDUSTRY PROVIDER
WA0192531OtherLABOR & INDUSTRY PROVIDER
WA7127327Medicaid