Provider Demographics
NPI:1699733840
Name:STALEY, CYNTHIA PATRICIA (MPT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:PATRICIA
Last Name:STALEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:PATRICIA
Other - Last Name:GAUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5775 SOUNDVIEW DR
Mailing Address - Street 2:B103
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335
Mailing Address - Country:US
Mailing Address - Phone:253-853-7956
Mailing Address - Fax:253-853-7958
Practice Address - Street 1:837 CALLAHAN DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310
Practice Address - Country:US
Practice Address - Phone:360-479-8477
Practice Address - Fax:360-479-8417
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8435489Medicaid
WA8855940Medicare ID - Type Unspecified
WA8435489Medicaid