=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952708562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW MAXWELL LMP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2014
-----------------------------------------------------
Last Update Date | 11/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 164TH ST SE STE. N
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98012-6301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-319-1123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 164TH ST SE STE. N
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98012-6301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-319-1123
-----------------------------------------------------
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 | 60498954
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------