Healthcare Provider Details

I. General information

NPI: 1174864540
Provider Name (Legal Business Name): GEORGIA CUDDEBACK L.M.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 ROY ST
SEATTLE WA
98109-4162
US

IV. Provider business mailing address

916 NE 65TH ST
SEATTLE WA
98115-5542
US

V. Phone/Fax

Practice location:
  • Phone: 206-267-0863
  • Fax:
Mailing address:
  • Phone: 206-267-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA00020373
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: