Healthcare Provider Details

I. General information

NPI: 1578216339
Provider Name (Legal Business Name): PEGAH REZVANI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8012 15TH AVE NW
SEATTLE WA
98117-3601
US

IV. Provider business mailing address

23828 CARTER RD # B
BOTHELL WA
98021-9408
US

V. Phone/Fax

Practice location:
  • Phone: 206-708-1212
  • Fax:
Mailing address:
  • Phone: 805-312-5719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number70113885
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number61206118
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: