Provider Demographics
NPI:1699266833
Name:STAVENS, GAREK (LMT)
Entity type:Individual
Prefix:
First Name:GAREK
Middle Name:
Last Name:STAVENS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16700 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3708
Mailing Address - Country:US
Mailing Address - Phone:971-570-6984
Mailing Address - Fax:
Practice Address - Street 1:1319 NE 134TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2717
Practice Address - Country:US
Practice Address - Phone:360-574-3141
Practice Address - Fax:360-326-1662
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60858653225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60858653OtherOTHER