Provider Demographics
NPI:1447836150
Name:REAVELY, RUSSELL ALLAN (LPTA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ALLAN
Last Name:REAVELY
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 10TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:WA
Mailing Address - Zip Code:98848-1376
Mailing Address - Country:US
Mailing Address - Phone:509-797-3531
Mailing Address - Fax:
Practice Address - Street 1:910 10TH ST SE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98810
Practice Address - Country:US
Practice Address - Phone:509-797-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60065774225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60065774Medicaid