=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396923959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OKSANA GAVRISHKEVICH LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2008
-----------------------------------------------------
Last Update Date | 05/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25854 108TH AVE SE
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98030-7737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-852-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20925 130TH PL SE
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98031-2247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-719-3033
-----------------------------------------------------
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 | MA00024975
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------