Provider Demographics
NPI:1902123110
Name:CAVIN, PENNY (PTA)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:CAVIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29835 45TH AVE S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2910
Mailing Address - Country:US
Mailing Address - Phone:206-429-3262
Mailing Address - Fax:
Practice Address - Street 1:1010 S 336TH ST
Practice Address - Street 2:STE 210
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6385
Practice Address - Country:US
Practice Address - Phone:253-835-8091
Practice Address - Fax:253-835-7102
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60033376225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant