Provider Demographics
NPI:1215156161
Name:DERRISO, JOY MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:MICHELLE
Last Name:DERRISO
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 1:4040 ORCHARD ST W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6606
Mailing Address - Country:US
Mailing Address - Phone:253-564-1560
Mailing Address - Fax:253-564-4449
Practice Address - Street 1:4040 ORCHARD ST W
Practice Address - Street 2:SUITE 100
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6606
Practice Address - Country:US
Practice Address - Phone:253-564-1560
Practice Address - Fax:253-564-4449
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60617275225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist