Healthcare Provider Details

I. General information

NPI: 1821641010
Provider Name (Legal Business Name): ANALEIGH MICHELLE OTIS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19068 JENSEN WAY NE #4B
POULSBO WA
98370
US

IV. Provider business mailing address

3070 EDEN VALLEY RD
PORT ANGELES WA
98363-9610
US

V. Phone/Fax

Practice location:
  • Phone: 360-271-2268
  • Fax:
Mailing address:
  • Phone: 360-460-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60950525
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: