Healthcare Provider Details

I. General information

NPI: 1396923959
Provider Name (Legal Business Name): OKSANA GAVRISHKEVICH LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25854 108TH AVE SE
KENT WA
98030-7737
US

IV. Provider business mailing address

20925 130TH PL SE
KENT WA
98031-2247
US

V. Phone/Fax

Practice location:
  • Phone: 253-852-2828
  • Fax:
Mailing address:
  • Phone: 206-719-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00024975
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: