Provider Demographics
NPI:1972731321
Name:NATURAL MYSTIC
Entity type:Organization
Organization Name:NATURAL MYSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMP
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHONTEL
Authorized Official - Middle Name:ANGEL MARIE
Authorized Official - Last Name:SUTTON HEIM
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-731-5190
Mailing Address - Street 1:PO BOX 2992
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528
Mailing Address - Country:US
Mailing Address - Phone:360-731-5190
Mailing Address - Fax:360-275-4412
Practice Address - Street 1:131 NE ROY BOAD RD
Practice Address - Street 2:SUITE A
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528
Practice Address - Country:US
Practice Address - Phone:360-731-5190
Practice Address - Fax:360-275-4412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty