Provider Demographics
NPI:1104347681
Name:PETTIT, CARLIE DAWN (LMP)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:DAWN
Last Name:PETTIT
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 1:3519 S 126TH ST
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2537
Mailing Address - Country:US
Mailing Address - Phone:206-241-7226
Mailing Address - Fax:
Practice Address - Street 1:4220 A ST SE STE 103
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-8620
Practice Address - Country:US
Practice Address - Phone:253-833-4800
Practice Address - Fax:253-833-4800
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60769575225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist