Provider Demographics
NPI:1154009074
Name:LIVELLA, THERESE (LMT)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:LIVELLA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 NE JOHN STORM AVE UNIT 707
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-0839
Mailing Address - Country:US
Mailing Address - Phone:913-961-1481
Mailing Address - Fax:
Practice Address - Street 1:305 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LA CENTER
Practice Address - State:WA
Practice Address - Zip Code:98629-5448
Practice Address - Country:US
Practice Address - Phone:913-961-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61453509225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist