Healthcare Provider Details

I. General information

NPI: 1396810594
Provider Name (Legal Business Name): TANYA R KUTZ LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 NORTH 18TH STREET
MOUNT VERNON WA
98273
US

IV. Provider business mailing address

124 NORTH 18TH STREET
MOUNT VERNON WA
98273
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-7885
  • Fax: 360-424-7223
Mailing address:
  • Phone: 360-428-7885
  • Fax: 360-424-7223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00009454
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: