Healthcare Provider Details

I. General information

NPI: 1669526372
Provider Name (Legal Business Name): THERESA G LYSTAD L.M.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12905 E SPRAGUE AVE
SPOKANE VALLEY WA
99216-0731
US

IV. Provider business mailing address

12905 E SPRAGUE AVE
SPOKANE VALLEY WA
99216-0731
US

V. Phone/Fax

Practice location:
  • Phone: 509-922-0303
  • Fax: 509-922-0657
Mailing address:
  • Phone: 509-922-0303
  • Fax: 509-922-0657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00010270
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: