=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891169991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHLETIC STRETCH THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2015
-----------------------------------------------------
Last Update Date | 11/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 105TH AVE NE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-486-6683
-----------------------------------------------------
Fax | 206-858-9655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 105TH AVE NE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-486-6683
-----------------------------------------------------
Fax | 206-858-9655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MASSAGE THERAPIST
-----------------------------------------------------
Name | SIOBHAN COLEMAN
-----------------------------------------------------
Credential | LMP
-----------------------------------------------------
Telephone | 208-486-6683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 60299782
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------