Healthcare Provider Details

I. General information

NPI: 1265917603
Provider Name (Legal Business Name): REBECCA ANN HRDLICKA MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 MAPLE AVE
SNOHOMISH WA
98290-2526
US

IV. Provider business mailing address

6232 139TH AVE SE
SNOHOMISH WA
98290-9309
US

V. Phone/Fax

Practice location:
  • Phone: 360-568-3319
  • Fax:
Mailing address:
  • Phone: 425-346-7047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60882965
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: