Healthcare Provider Details

I. General information

NPI: 1417002064
Provider Name (Legal Business Name): CRYSTAL L DAVIS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL L HOTTELL LMP

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 1ST AVE. SW
CASTLE ROCK WA
98611
US

IV. Provider business mailing address

224 PAINE RD
CASTLE ROCK WA
98611-8708
US

V. Phone/Fax

Practice location:
  • Phone: 360-274-2353
  • Fax: 360-274-2354
Mailing address:
  • Phone: 360-274-2353
  • Fax: 360-274-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00019024
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: