Healthcare Provider Details

I. General information

NPI: 1720289234
Provider Name (Legal Business Name): COLEEN ERIN SMALL LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 5TH AVE NE SUITE 102
SEATTLE WA
98115-4180
US

IV. Provider business mailing address

PO BOX 30068
SEATTLE WA
98113-2068
US

V. Phone/Fax

Practice location:
  • Phone: 206-609-7282
  • Fax:
Mailing address:
  • Phone: 206-609-7282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA00006402
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: