Provider Demographics
NPI:1861185324
Name:THEISEN, AMANDA (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:THEISEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:GRACE
Other - Last Name:THEISEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:1309 HARBOR AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-1784
Mailing Address - Country:US
Mailing Address - Phone:206-906-9207
Mailing Address - Fax:
Practice Address - Street 1:2815 SW NEVADA ST UNIT A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-2537
Practice Address - Country:US
Practice Address - Phone:320-339-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61388668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist