Healthcare Provider Details

I. General information

NPI: 1205157344
Provider Name (Legal Business Name): ESTHER WALBERG DERUSHA LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 COULEE BLVD.
ELECTRIC CITY WA
99123
US

IV. Provider business mailing address

P.O. BOX 657 8 COULEE BLVD.
ELECTRIC CITY WA
99123
US

V. Phone/Fax

Practice location:
  • Phone: 509-633-0777
  • Fax:
Mailing address:
  • Phone: 509-633-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00005237
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: