Healthcare Provider Details

I. General information

NPI: 1750752531
Provider Name (Legal Business Name): MICHELLE SPENCER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 NW BUCKLIN HILL RD
SILVERDALE WA
98383-8503
US

IV. Provider business mailing address

3595 NW BUCKLIN HILL RD
SILVERDALE WA
98383-8503
US

V. Phone/Fax

Practice location:
  • Phone: 360-698-3140
  • Fax: 360-692-1441
Mailing address:
  • Phone: 317-652-6691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60392541
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: