Provider Demographics
NPI:1154986321
Name:PIDGORODETSKAYA, TATYANA MIKHAILOVNA (LMT)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:MIKHAILOVNA
Last Name:PIDGORODETSKAYA
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 1:17620 140TH AVE SE
Mailing Address - Street 2:SUITE C-5
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058
Mailing Address - Country:US
Mailing Address - Phone:425-228-2225
Mailing Address - Fax:425-226-3718
Practice Address - Street 1:17620 140TH AVE SE
Practice Address - Street 2:SUITE C-5
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058
Practice Address - Country:US
Practice Address - Phone:425-228-2225
Practice Address - Fax:425-226-3718
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60290361225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist