Healthcare Provider Details

I. General information

NPI: 1457412702
Provider Name (Legal Business Name): ERIN MARY BLACK LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9015 HOLMAN RD NW STE 3
SEATTLE WA
98117-3481
US

IV. Provider business mailing address

9015 HOLMAN RD NW STE 3
SEATTLE WA
98117-3481
US

V. Phone/Fax

Practice location:
  • Phone: 206-782-8500
  • Fax: 206-784-4020
Mailing address:
  • Phone: 206-782-8500
  • Fax: 206-784-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00016624
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: