Healthcare Provider Details

I. General information

NPI: 1356500367
Provider Name (Legal Business Name): ROXANNE CLEMENCE LMP, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16408 3RD AVE SE
BOTHELL WA
98012-5951
US

IV. Provider business mailing address

16408 3RD AVE SE
BOTHELL WA
98012-5951
US

V. Phone/Fax

Practice location:
  • Phone: 425-741-4444
  • Fax:
Mailing address:
  • Phone: 425-741-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00023996
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: