Provider Demographics
NPI:1679754170
Name:RACOUILLAT, MELISSA (DPT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RACOUILLAT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9955
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-0955
Mailing Address - Country:US
Mailing Address - Phone:415-680-0247
Mailing Address - Fax:
Practice Address - Street 1:14028 SE PETROVITSKY RD
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8933
Practice Address - Country:US
Practice Address - Phone:425-272-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 34048225100000X
WAPT60383867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1679754170Medicaid
WA328947OtherWA L&I
WA328948OtherWA L&I
CAZZZ23789ZMedicare Oscar/Certification
WA328947OtherWA L&I
WAG8924639Medicare PIN