Provider Demographics
NPI:1871276790
Name:SECRIST, TAYLRE R (DPT)
Entity type:Individual
Prefix:
First Name:TAYLRE
Middle Name:R
Last Name:SECRIST
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TAYLRE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 S LAVENTURE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-6033
Mailing Address - Country:US
Mailing Address - Phone:360-424-7041
Mailing Address - Fax:360-424-2418
Practice Address - Street 1:1017 20TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2505
Practice Address - Country:US
Practice Address - Phone:360-424-7041
Practice Address - Fax:360-424-2456
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61446728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2257399Medicaid