=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326354408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA S WILLARD LMP, CNB, PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2010
-----------------------------------------------------
Last Update Date | 05/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4821 NW ANDERSON HILL RD
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-9209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-471-4144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4821 NW ANDERSON HILL RD
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-9209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-471-4144
-----------------------------------------------------
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 | MA 60226312
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------