Healthcare Provider Details

I. General information

NPI: 1447584040
Provider Name (Legal Business Name): SONYA MARIE ELHARDT LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 BROADWAY
LONGVIEW WA
98632
US

IV. Provider business mailing address

1329 BROADWAY SUITE 203
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-3442
  • Fax:
Mailing address:
  • Phone: 360-636-3442
  • Fax: 360-636-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMA00003455
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00003455
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: