Provider Demographics
NPI:1063525129
Name:ULRICH, SHANNA L (LMP)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:L
Last Name:ULRICH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5211
Mailing Address - Country:US
Mailing Address - Phone:360-882-7312
Mailing Address - Fax:
Practice Address - Street 1:3425 SE 192ND AVE
Practice Address - Street 2:STE 109
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1466
Practice Address - Country:US
Practice Address - Phone:360-253-7696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist