Provider Demographics
NPI:1962743401
Name:STRADER, SHIRLEY A (LMP)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:STRADER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3219
Mailing Address - Country:US
Mailing Address - Phone:509-452-8418
Mailing Address - Fax:
Practice Address - Street 1:307 S 12TH AVE
Practice Address - Street 2:SUITE #20
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3100
Practice Address - Country:US
Practice Address - Phone:509-895-4293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00005391225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist