Healthcare Provider Details

I. General information

NPI: 1356460398
Provider Name (Legal Business Name): KOLLEEN K KOHLRUS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 STORKSON RD BLDG 2-B
CLINTON WA
98236-9514
US

IV. Provider business mailing address

3301 NE 11TH ST
RENTON WA
98056-3452
US

V. Phone/Fax

Practice location:
  • Phone: 360-221-8552
  • Fax:
Mailing address:
  • Phone: 206-280-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00004101
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: