Provider Demographics
NPI:1063739167
Name:ANDERSON, TINA MARIE (LMP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:ANDERSON
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 1:346 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9522
Mailing Address - Country:US
Mailing Address - Phone:360-785-4316
Mailing Address - Fax:
Practice Address - Street 1:346 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:WINLOCK
Practice Address - State:WA
Practice Address - Zip Code:98596-9522
Practice Address - Country:US
Practice Address - Phone:360-785-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60126580225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist