1699733840 NPI number — CYNTHIA PATRICIA STALEY MPT

Table of content: CYNTHIA PATRICIA STALEY MPT (NPI 1699733840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699733840 NPI number — CYNTHIA PATRICIA STALEY MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STALEY
Provider First Name:
CYNTHIA
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAUIN
Provider Other First Name:
CYNTHIA
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699733840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5775 SOUNDVIEW DR
Provider Second Line Business Mailing Address:
B103
Provider Business Mailing Address City Name:
GIG HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-853-7956
Provider Business Mailing Address Fax Number:
253-853-7958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
837 CALLAHAN DRIVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-479-8477
Provider Business Practice Location Address Fax Number:
360-479-8417
Provider Enumeration Date:
05/03/2006

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:  PT00009725 , 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)

  • Identifier: 8435489 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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