Healthcare Provider Details

I. General information

NPI: 1831535699
Provider Name (Legal Business Name): ELLEN ELIZABETH KLISSUS CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 VETERANS DR SW RM 263
TACOMA WA
98493-0003
US

IV. Provider business mailing address

7625 E KAREN LN
PORT ORCHARD WA
98366-8528
US

V. Phone/Fax

Practice location:
  • Phone: 253-583-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60346418
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number80817
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: