Healthcare Provider Details

I. General information

NPI: 1164630620
Provider Name (Legal Business Name): SANDRA T BITTNER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MAIN ST P
BUCKLEY WA
98321
US

IV. Provider business mailing address

30821 SE 392ND ST
ENUMCLAW WA
98022-7770
US

V. Phone/Fax

Practice location:
  • Phone: 253-709-2570
  • Fax: 360-829-1836
Mailing address:
  • Phone: 253-709-2570
  • Fax: 360-829-1836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number53064007
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: