Healthcare Provider Details

I. General information

NPI: 1457608010
Provider Name (Legal Business Name): GREGGORY MARVIN HEUSON L.M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 NE 94TH AVE STE D
VANCOUVER WA
98662-6180
US

IV. Provider business mailing address

12407 NE 41ST ST
VANCOUVER WA
98682-6813
US

V. Phone/Fax

Practice location:
  • Phone: 360-601-3985
  • Fax:
Mailing address:
  • Phone: 360-601-3985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60293267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: