Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA00014743 | WA |
NPI | 1003956962 |
---|---|
Provider Name | Mr. Glen Erickson |
First Address | Olympia, WA 98506-4665 |
Second Address | Olympia, WA 98506-4246 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2007 |
Last Update Date | 08/07/2007 |