Provider Demographics
NPI:1871698050
Name:GODFREY, RENA R (MPT)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:R
Last Name:GODFREY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 132ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-7203
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:1901 S CEDAR ST STE B1
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2305
Practice Address - Country:US
Practice Address - Phone:253-272-6910
Practice Address - Fax:253-383-4218
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGO9746OtherPREMERA BLUE CROSS
WAP00286357OtherRAILROAD MEDICARE
WAGO9746OtherREGENCE BLUE SHIELD
WA8341430Medicaid
WA0197667OtherDEPT OF LABOR & INDUSTRY
WA0296931OtherL & I
WA0296931OtherL & I
WAGO9746OtherREGENCE BLUE SHIELD