Provider Demographics
NPI:1588141568
Name:BLUE WAVE BODYWORK
Entity type:Organization
Organization Name:BLUE WAVE BODYWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMT
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-320-7899
Mailing Address - Street 1:12014 SE MILL PLAIN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4044
Mailing Address - Country:US
Mailing Address - Phone:503-320-7899
Mailing Address - Fax:
Practice Address - Street 1:12014 SE MILL PLAIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4044
Practice Address - Country:US
Practice Address - Phone:503-320-7899
Practice Address - Fax:360-836-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60811941225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty