Healthcare Provider Details

I. General information

NPI: 1487659983
Provider Name (Legal Business Name): ANGLEA MARIE ALLEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 17TH AVE APT 2
LONGVIEW WA
98632-2265
US

IV. Provider business mailing address

1122 17TH AVE APT 2
LONGVIEW WA
98632-2265
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-5805
  • Fax:
Mailing address:
  • Phone: 360-577-5805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00020844
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: