Provider Demographics
NPI:1588867246
Name:LEESE, DOUGLAS ALAN (LMT)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:LEESE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:DOUGLAS
Other - Middle Name:A
Other - Last Name:LEESE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MASSAGE LICENSE
Mailing Address - Street 1:PO BOX 4303
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-4303
Mailing Address - Country:US
Mailing Address - Phone:509-429-8051
Mailing Address - Fax:
Practice Address - Street 1:616 IRONWOOD ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9545
Practice Address - Country:US
Practice Address - Phone:509-429-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016504225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA165116OtherLABOR AND INDUSTRIES