Provider Demographics
NPI:1447341946
Name:ACTIVE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COURTENEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEALKO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CERT MDT, CSCS
Authorized Official - Phone:206-284-9088
Mailing Address - Street 1:1415 W DRAVUS ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-1716
Mailing Address - Country:US
Mailing Address - Phone:206-284-9088
Mailing Address - Fax:206-285-4946
Practice Address - Street 1:1415 W DRAVUS ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-1716
Practice Address - Country:US
Practice Address - Phone:206-284-9088
Practice Address - Fax:206-285-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008630174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty