Provider Demographics
NPI:1528331402
Name:MOUNTLAKE SPORTS & PHYSICAL THERAPY PS
Entity type:Organization
Organization Name:MOUNTLAKE SPORTS & PHYSICAL THERAPY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-379-8120
Mailing Address - Street 1:9505 19TH AVE SE
Mailing Address - Street 2:101
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3853
Mailing Address - Country:US
Mailing Address - Phone:425-379-8120
Mailing Address - Fax:425-338-1789
Practice Address - Street 1:9505 19TH AVE SE
Practice Address - Street 2:101
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3853
Practice Address - Country:US
Practice Address - Phone:425-379-8120
Practice Address - Fax:425-338-1789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60178380225100000X
WAMA00018299225700000X
WAMA00015079225700000X
WAPT00003917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084650Medicaid
WA0151396OtherDEPARTMENT OF LABOR & INDUSTRIES