Healthcare Provider Details

I. General information

NPI: 1649938242
Provider Name (Legal Business Name): MICHAEL SPENCER KUPERSTEIN MASSAGE THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4248 LAKE WASHINGTON BLVD SE
BELLEVUE WA
98006-1110
US

IV. Provider business mailing address

4248 LAKE WASHINGTON BLVD SE
BELLEVUE WA
98006-1110
US

V. Phone/Fax

Practice location:
  • Phone: 845-444-0148
  • Fax:
Mailing address:
  • Phone: 845-444-0148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60897071
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: