Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA60936482 | WA |
NPI | 1003470154 |
---|---|
Provider Name | Brian James Petrich |
First Address | Olalla, WA 98359-9594 |
Second Address | Port Orchard, WA 98366-3108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2019 |
Last Update Date | 24/04/2019 |