1215905278 NPI number — MS. TAMMY DEROCHE DPT

Table of content: MS. TAMMY DEROCHE DPT (NPI 1215905278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215905278 NPI number — MS. TAMMY DEROCHE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEROCHE
Provider First Name:
TAMMY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1215905278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6520 226TH PL SE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98027-8969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-392-8611
Provider Business Mailing Address Fax Number:
425-392-9012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6520 226TH PL SE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-8969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-392-8611
Provider Business Practice Location Address Fax Number:
425-392-9012
Provider Enumeration Date:
03/08/2006

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:  PT00009705 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 70010260 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PTL-6970 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8422792 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7111645 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 196053 . This is a "DEPT OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8906265 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4295DE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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