1811516297 NPI number — DR. KACIE MICHELLE SHIVELY PT, DPT, ACSM-EP

Table of content: DR. KACIE MICHELLE SHIVELY PT, DPT, ACSM-EP (NPI 1811516297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811516297 NPI number — DR. KACIE MICHELLE SHIVELY PT, DPT, ACSM-EP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIVELY
Provider First Name:
KACIE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ACSM-EP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811516297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 S TEXAS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-4085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-947-8600
Provider Business Mailing Address Fax Number:
509-236-8095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5020 W CLEARWATER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-934-3309
Provider Business Practice Location Address Fax Number:
509-236-8095
Provider Enumeration Date:
04/15/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT60723995 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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