Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NX0100X | Occupational Health | 602668079 | WA |
Y | 225700000X | Massage Therapist | 60284012 | WA |
NPI | 1710246590 |
---|---|
Provider Name | Sarah Michelle Willow |
First Address | Centralia, WA 98531-1255 |
Second Address | Kent, WA 98030-7458 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2012 |
Last Update Date | 16/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
60284012 | MASSAGE LICENSE (01) | WA |