1174680276 NPI number — MARIE TERESE MATTESON MS LMT RC CCHT

Table of content: MARIE TERESE MATTESON MS LMT RC CCHT (NPI 1174680276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174680276 NPI number — MARIE TERESE MATTESON MS LMT RC CCHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTESON
Provider First Name:
MARIE
Provider Middle Name:
TERESE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS LMT RC CCHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTESON-OLSEN
Provider Other First Name:
MARIE
Provider Other Middle Name:
TERESE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174680276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 GIRARD ST
Provider Second Line Business Mailing Address:
ALTERNATE ADDRESS 3 SPRING ROAD
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-4004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-815-7180
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 GIRARD ST
Provider Second Line Business Practice Location Address:
ALTNERATE ADDRESS 3 SPRING ROAD
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-815-7180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP1600X , with the licence number:  RC52217 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 146N00000X , with the licence number: 1164236 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RC52217 . This is a "REGISTERED COUNSELOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: HP60104589 . This is a "STATE OF WASHINGTON DOH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MA10351 . This is a "LIC MASSAGE PRACTITIIONER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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