Healthcare Provider Details

I. General information

NPI: 1609226471
Provider Name (Legal Business Name): FREDERICK MARTIN SHAVER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W GOWE ST
KENT WA
98032-5892
US

IV. Provider business mailing address

325 W GOWE ST
KENT WA
98032-5892
US

V. Phone/Fax

Practice location:
  • Phone: 253-833-7444
  • Fax: 253-661-8631
Mailing address:
  • Phone: 253-833-7444
  • Fax: 253-661-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.70121001
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60546268
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: