Provider Demographics
NPI:1902106719
Name:BLAIS, TIMOTHY
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:BLAIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7513 LAKEWOOD DR W
Mailing Address - Street 2:APT F-9
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3163
Mailing Address - Country:US
Mailing Address - Phone:253-241-6043
Mailing Address - Fax:
Practice Address - Street 1:7513 LAKEWOOD DR W
Practice Address - Street 2:APT F-9
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3163
Practice Address - Country:US
Practice Address - Phone:253-241-6043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60190402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist