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General NPI Number Information
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NPI Number | 1972099018
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Entity Type | Individual
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Provider Name | IRENA V POTSELUYKO LMT
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Gender | Female
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Dates
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Enumeration Date | 07/02/2018
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Last Update Date | 07/02/2018
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Provider Practice Location Address
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Address Line | 25854 108TH AVE SE
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City | KENT
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State | WA
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Zip | 98030-7737
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Country | US
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Telephone | 206-227-2735
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Fax | 253-852-2828
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Provider Business Mailing Address
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Address Line | 10515 SE 273RD PL
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City | KENT
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State | WA
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Zip | 98030-7671
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Country | US
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Telephone | 206-227-2735
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA60832939
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License Number State | WA
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