Provider Demographics
NPI:1902060197
Name:ELLISON, GRACE BIRD (GPT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:BIRD
Last Name:ELLISON
Suffix:
Gender:F
Credentials:GPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:GRACE
Other - Last Name:BIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
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:425-337-9556
Mailing Address - Fax:425-357-9186
Practice Address - Street 1:1519 132ND ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-7203
Practice Address - Country:US
Practice Address - Phone:425-337-9556
Practice Address - Fax:425-357-9186
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8948510OtherL&I CRIME
WA0273751OtherDEPT OF L&I
WA1020BIOtherREGENCE
WAP00738996OtherRAILROAD MEDICARE IRG
WA1170BIOtherREGENCE
WA2060BIOtherREGENCE
WA8522666OtherDSHS
WAP00664566OtherRAILROAD MEDICARE
WA239386OtherL&I
WA4030BIOtherREGENCE
WA6097BIOtherREGENCE
WA239347OtherL&I
WA2588BIOtherREGENCE
WA0157BIOtherREGENCE
WA5029BIOtherREGENCE
WA8948544OtherL&I CRIME
WA1020BIOtherREGENCE
WA8948510OtherL&I CRIME
WA8522666OtherDSHS
WA239347OtherL&I