Healthcare Provider Details

I. General information

NPI: 1932488004
Provider Name (Legal Business Name): MARTHA MOEONONO LAUMOLI BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S PROCTOR ST
TACOMA WA
98405-2047
US

IV. Provider business mailing address

1201 S PROCTOR ST
TACOMA WA
98405-2047
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-5937
  • Fax: 253-566-2252
Mailing address:
  • Phone: 253-396-5937
  • Fax: 253-566-2252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberCG60215106
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: