Healthcare Provider Details

I. General information

NPI: 1225180870
Provider Name (Legal Business Name): CYNTHIA ANN HYDRICK LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 NE 44TH ST
VANCOUVER WA
98663-2186
US

IV. Provider business mailing address

3303 NE 44TH ST
VANCOUVER WA
98663-2186
US

V. Phone/Fax

Practice location:
  • Phone: 360-823-0888
  • Fax: 360-823-0882
Mailing address:
  • Phone: 360-823-0888
  • Fax: 360-823-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00011855
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: