Healthcare Provider Details

I. General information

NPI: 1225254873
Provider Name (Legal Business Name): ACTIVE HEALING MASSAGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6995 LITTLEROCK RD SW
TUMWATER WA
98512-7246
US

IV. Provider business mailing address

6995 LITTLEROCK RD SW
TUMWATER WA
98512-7246
US

V. Phone/Fax

Practice location:
  • Phone: 360-357-3009
  • Fax:
Mailing address:
  • Phone: 360-357-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAMANTHA C WIKAN
Title or Position: OWNER
Credential: LMT
Phone: 360-357-3009