Healthcare Provider Details

I. General information

NPI: 1538312830
Provider Name (Legal Business Name): MARY LOU HAASE L.M.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 GOLDENEYE STREET SW
OCEAN SHORES WA
98569
US

IV. Provider business mailing address

PO BOX 1758 129 GOLDENEYE STREET SW
OCEAN SHORES WA
98569-1758
US

V. Phone/Fax

Practice location:
  • Phone: 360-581-5368
  • Fax:
Mailing address:
  • Phone: 360-581-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017761
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: