Provider Demographics
NPI:1053908681
Name:LOPEZ, DANIEL (PTA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2334
Mailing Address - Country:US
Mailing Address - Phone:425-377-3039
Mailing Address - Fax:
Practice Address - Street 1:16259 SYLVESTER RD SW STE 102
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3094
Practice Address - Country:US
Practice Address - Phone:206-242-5186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61087810225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant