Healthcare Provider Details

I. General information

NPI: 1063739167
Provider Name (Legal Business Name): TINA MARIE ANDERSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 RUSSELL RD
WINLOCK WA
98596-9522
US

IV. Provider business mailing address

346 RUSSELL RD
WINLOCK WA
98596-9522
US

V. Phone/Fax

Practice location:
  • Phone: 360-785-4316
  • Fax:
Mailing address:
  • Phone: 360-785-4316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60126580
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: