Provider Demographics
NPI:1144305350
Name:KHADDURI, LUCIE (BSPT)
Entity type:Individual
Prefix:
First Name:LUCIE
Middle Name:
Last Name:KHADDURI
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:
Other - First Name:LUCIE
Other - Middle Name:
Other - Last Name:ROMERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSPT
Mailing Address - Street 1:3425 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5425
Mailing Address - Country:US
Mailing Address - Phone:360-493-4015
Mailing Address - Fax:
Practice Address - Street 1:3425 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5425
Practice Address - Country:US
Practice Address - Phone:360-493-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0291092OtherDEPT. OF LABOR AND INDUSTRIES
WA650023899OtherRAILROAD MEDICARE
WA8542KHOtherREGENCE BLUE SHIELD
WA8336786Medicaid
WA8936913OtherCRIME VICTIMS
WA160515OtherDEPT OF LABOR & INDUSTRY
WAA008OtherTRICARE
WAAB29311Medicare ID - Type UnspecifiedPIERCE COUNTY