Provider Demographics
NPI:1104101831
Name:MOODY, CHRISTINE LOUISE (LMP)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:LOUISE
Last Name:MOODY
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 1:2567 25TH LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-3812
Mailing Address - Country:US
Mailing Address - Phone:360-791-7008
Mailing Address - Fax:
Practice Address - Street 1:7914 MARTIN WAY E
Practice Address - Street 2:STE 8
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5728
Practice Address - Country:US
Practice Address - Phone:360-339-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60181438225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0272790OtherSTATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES