=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447066436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC NORTHWEST MASSAGE AND CRYOTHERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2024
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 LAKE BELLEVUE DR STE 208
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98005-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-945-7683
-----------------------------------------------------
Fax | 206-260-4339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7609 SE 29TH ST
-----------------------------------------------------
City | MERCER ISLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98040-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-945-7683
-----------------------------------------------------
Fax | 206-260-4339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST, OWNER
-----------------------------------------------------
Name | MS. DAENNA LYNNE JANUARY
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 561-945-7683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------