Healthcare Provider Details

I. General information

NPI: 1154636058
Provider Name (Legal Business Name): ELSBETH D. MOODY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELSBETH D. BELLAH LMT

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 REGENTS BLVD. STE 204
FIRCREST WA
98466
US

IV. Provider business mailing address

1033 REGENTS BLVD. STE 204
FIRCREST WA
98466
US

V. Phone/Fax

Practice location:
  • Phone: 253-564-1288
  • Fax: 253-564-1752
Mailing address:
  • Phone: 253-564-1288
  • Fax: 253-564-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60129821
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: