Provider Demographics
NPI:1265701395
Name:LIBERTY PHYSICAL THERAPY
Entity type:Organization
Organization Name:LIBERTY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT PHD
Authorized Official - Phone:206-778-6405
Mailing Address - Street 1:9000 SE 45TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-4144
Mailing Address - Country:US
Mailing Address - Phone:206-778-6405
Mailing Address - Fax:
Practice Address - Street 1:1820 12TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2438
Practice Address - Country:US
Practice Address - Phone:206-860-3746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00002906261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy