=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033444336
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARON LEE MCPHERSON WIDEN LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2009
-----------------------------------------------------
Last Update Date | 09/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23369 PRINGLE STREET POB 52
-----------------------------------------------------
City | CLEARLAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98235-0052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-854-9765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23369 PRINGLE STREET
-----------------------------------------------------
City | CLEARLAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98235-0052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-708-3246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA60102554
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------