Provider Demographics
NPI:1598815995
Name:MCSWANE-ICEBERG, JULIE LYN (LMP)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:LYN
Last Name:MCSWANE-ICEBERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1548 N EDISON ST
Mailing Address - Street 2:C-202
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1462
Mailing Address - Country:US
Mailing Address - Phone:509-783-2860
Mailing Address - Fax:
Practice Address - Street 1:5219 W CLEARWATER AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1914
Practice Address - Country:US
Practice Address - Phone:509-736-6605
Practice Address - Fax:509-736-6607
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist