Healthcare Provider Details

I. General information

NPI: 1437920683
Provider Name (Legal Business Name): LISHU TANG MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 11/19/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16934 116TH AVE SE
RENTON WA
98058
US

IV. Provider business mailing address

16934 116TH AVE SE
RENTON WA
98058
US

V. Phone/Fax

Practice location:
  • Phone: 425-454-0199
  • Fax: 425-516-7878
Mailing address:
  • Phone: 425-454-0199
  • Fax: 425-516-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA61322120
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: