Healthcare Provider Details

I. General information

NPI: 1942576590
Provider Name (Legal Business Name): DANYEL LEANN PIVA LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N AMBOY AVE
YACOLT WA
98675-5442
US

IV. Provider business mailing address

PO BOX 516
YACOLT WA
98675-0699
US

V. Phone/Fax

Practice location:
  • Phone: 360-668-6085
  • Fax:
Mailing address:
  • Phone: 360-686-0851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00023512
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: