=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205349412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLI LORETTA BOESS MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2017
-----------------------------------------------------
Last Update Date | 11/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2530 NE KRESKY AVE STE B
-----------------------------------------------------
City | CHEHALIS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98532-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-996-4778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 NE 2ND ST
-----------------------------------------------------
City | WINLOCK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98596-9460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-520-9943
-----------------------------------------------------
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 | MA60659966
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------