Provider Demographics
NPI:1215049622
Name:KELLEHER, DARRYL MATHEW (BSPT)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:MATHEW
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 PACIFIC AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7800
Mailing Address - Country:US
Mailing Address - Phone:253-475-4415
Mailing Address - Fax:253-475-3034
Practice Address - Street 1:3711 PACIFIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7800
Practice Address - Country:US
Practice Address - Phone:253-475-4415
Practice Address - Fax:253-475-3034
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32331OtherDEPT OF L AND I
WA4454296OtherAETNA PPO, POS, EPO
WA650016424OtherRAILROAD MEDICARE
WA8914812OtherSOUNDVIEW CRIMEVICTIMSLI
WA336786200OtherUS DEPT OF LABOR-OWCP-ACS
WA7160054Medicaid
WA8333940Medicaid
WA8914810OtherCRIME VICTIMS L AND I
WA2378617OtherAETNA HMO, QPOS US ACCESS
WAKE0554OtherREGENCE BLUE SHIELD
WA8914812OtherSOUNDVIEW CRIMEVICTIMSLI