Provider Demographics
NPI:1316315898
Name:WISE, MICHELLE LINDSAY (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LINDSAY
Last Name:WISE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LINDSAY
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17802 W LAKE DESIRE DR SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-9562
Mailing Address - Country:US
Mailing Address - Phone:425-272-5564
Mailing Address - Fax:425-272-2907
Practice Address - Street 1:19032 66TH AVE S STE C100
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-2116
Practice Address - Country:US
Practice Address - Phone:425-272-5564
Practice Address - Fax:425-272-2907
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60601196225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist