Healthcare Provider Details

I. General information

NPI: 1336575398
Provider Name (Legal Business Name): DARYLE SULLIVAN L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 STATE AVE SUITE A
MARYSVILLE WA
98270-2235
US

IV. Provider business mailing address

9501 STATE AVE SUITE A
MARYSVILLE WA
98270-2235
US

V. Phone/Fax

Practice location:
  • Phone: 360-651-8264
  • Fax: 360-658-9021
Mailing address:
  • Phone: 360-651-8264
  • Fax: 360-658-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00008878
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT110567
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: