Healthcare Provider Details

I. General information

NPI: 1184902116
Provider Name (Legal Business Name): LIDIYA KOZLOVA LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 CENTER ST DR STE N AIM PHYSICAL THERAPY
TACOMA WA
98327
US

IV. Provider business mailing address

5517 BRIDGEPORT WAY W # D7
UNIVERSITY PLACE WA
98467-2004
US

V. Phone/Fax

Practice location:
  • Phone: 253-964-1559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60228696
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: