Healthcare Provider Details

I. General information

NPI: 1497895890
Provider Name (Legal Business Name): CAROLA DE KEIZER CR, LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 FIR ST NE
OLYMPIA WA
98506-3429
US

IV. Provider business mailing address

1822 FIR ST NE
OLYMPIA WA
98506-3429
US

V. Phone/Fax

Practice location:
  • Phone: 360-561-5875
  • Fax:
Mailing address:
  • Phone: 360-561-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00014481
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: