Healthcare Provider Details

I. General information

NPI: 1417022849
Provider Name (Legal Business Name): MELANIE MOORE BENNETT LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 BISHOP RD SW STE 103
TUMWATER WA
98512-7303
US

IV. Provider business mailing address

2728 31ST CT SE
OLYMPIA WA
98501-3916
US

V. Phone/Fax

Practice location:
  • Phone: 360-459-9000
  • Fax: 360-459-9183
Mailing address:
  • Phone: 360-352-7249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAOOOO6291
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: