Provider Demographics
NPI:1285452920
Name:DAN, KATHLEEN MARIE (LMT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DAN
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 1:500 W MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4252
Mailing Address - Country:US
Mailing Address - Phone:360-623-1214
Mailing Address - Fax:360-623-1215
Practice Address - Street 1:500 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4252
Practice Address - Country:US
Practice Address - Phone:360-623-1214
Practice Address - Fax:360-623-1215
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61403618225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist