Provider Demographics
NPI:1285791657
Name:SULLIVAN, MARLENE RENEE' (LMT)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:RENEE'
Last Name:SULLIVAN
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 1:933 W. 3RD AVE. SUITE 214
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201
Mailing Address - Country:US
Mailing Address - Phone:509-230-2112
Mailing Address - Fax:509-747-5443
Practice Address - Street 1:933 W. 3RD AVE SUITE 214
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201
Practice Address - Country:US
Practice Address - Phone:509-230-2112
Practice Address - Fax:509-747-5443
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011043174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00011043OtherMASSAGE THERAPIST
WA118072OtherLABOR & INDUSTRIES