Active NPI
Russell Allan Reavely, LPTA
- Physical Therapy Assistant
- Quincy, WA
National Provider Identifier
1447836150
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 60065774
- Practice address
- 910 10TH St SE
Quincy, WA 98810 - Phone
- (509) 797-3531
- NPI assigned
- Mar 23, 2021
- Last updated
- Mar 23, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 60065774 | WA | Primary |
Addresses
Primary practice location
910 10TH St SE
Quincy, WA 98810
Mailing address
908 10TH Ave SW
Quincy, WA 98848-1376
Phone (509) 797-3531
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 60065774 | Medicaid | WA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 60065774 | WA | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1616457600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1616457600000",
"number": "1447836150",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "908 10TH AVE SW",
"city": "QUINCY",
"state": "WA",
"postal_code": "988481376",
"telephone_number": "509-797-3531"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "910 10TH ST SE",
"city": "QUINCY",
"state": "WA",
"postal_code": "98810",
"telephone_number": "509-797-3531"
}
],
"practiceLocations": [],
"basic": {
"last_name": "REAVELY",
"first_name": "RUSSELL",
"middle_name": "ALLAN",
"name_prefix": "Mr.",
"credential": "LPTA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-03-23",
"last_updated": "2021-03-23",
"certification_date": "2021-02-28",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "WA",
"license": "60065774",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "60065774",
"state": "WA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Quincy, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 23, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.