Provider Demographics
NPI:1124284302
Name:MACDONALD, SAMANTHA GAYE (LMP)
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:GAYE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5013 S 56TH ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-1348
Mailing Address - Country:US
Mailing Address - Phone:253-475-0550
Mailing Address - Fax:253-475-0596
Practice Address - Street 1:5013 S 56TH ST
Practice Address - Street 2:SUITE H
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-1348
Practice Address - Country:US
Practice Address - Phone:253-475-0550
Practice Address - Fax:253-475-0596
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60012060225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist