Provider Demographics
NPI:1104582865
Name:CHUMOV, TYESE-ANDREYA A (LMT)
Entity type:Individual
Prefix:
First Name:TYESE-ANDREYA
Middle Name:A
Last Name:CHUMOV
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TYESE
Other - Middle Name:
Other - Last Name:CHUMOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA 61214687
Mailing Address - Street 1:4127 E HARTSON AVE # 99202
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-5111
Mailing Address - Country:US
Mailing Address - Phone:509-991-7229
Mailing Address - Fax:
Practice Address - Street 1:16201 E INDIANA AVE STE 1111
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2838
Practice Address - Country:US
Practice Address - Phone:509-927-8997
Practice Address - Fax:509-927-3919
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61214687225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist