Provider Demographics
NPI:1003021569
Name:DEGRAW, TIARI GARDNER (PTA)
Entity type:Individual
Prefix:
First Name:TIARI
Middle Name:GARDNER
Last Name:DEGRAW
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 1:5802 162ND AVE E
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-3108
Mailing Address - Country:US
Mailing Address - Phone:253-891-3108
Mailing Address - Fax:
Practice Address - Street 1:1010 S 336TH ST STE 120
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7354
Practice Address - Country:US
Practice Address - Phone:866-835-8091
Practice Address - Fax:253-835-7102
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant