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General NPI Number Information
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NPI Number | 1174130793
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Entity Type | Individual
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Provider Name | GEORGIA LEANN FAHL LMT
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Gender | Female
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Dates
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Enumeration Date | 09/28/2020
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Last Update Date | 09/28/2020
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Provider Practice Location Address
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Address Line | 122 5TH AVE S # 122B
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City | EDMONDS
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State | WA
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Zip | 98020-3423
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Country | US
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Telephone | 707-812-0669
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Fax |
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Provider Business Mailing Address
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Address Line | 23306 EDMONDS WAY APT G206
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City | EDMONDS
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State | WA
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Zip | 98026-8658
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Country | US
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Telephone | 707-812-0669
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA61102809
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License Number State | WA
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