Healthcare Provider Details

I. General information

NPI: 1336491364
Provider Name (Legal Business Name): MATTHEW HUOT LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4322 RUCKER AVE
EVERETT WA
98203-2233
US

IV. Provider business mailing address

1124 WETMORE AVE
EVERETT WA
98201-1554
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-5454
  • Fax:
Mailing address:
  • Phone: 425-232-5859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 00017688
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: