Provider Demographics
NPI:1104295013
Name:ENGSTROM, KARLY (PTA)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:
Last Name:ENGSTROM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11915 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4997
Mailing Address - Country:US
Mailing Address - Phone:509-228-9404
Mailing Address - Fax:
Practice Address - Street 1:11915 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4997
Practice Address - Country:US
Practice Address - Phone:509-228-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60501101225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant