1760515431 NPI number — TAMARA BURT LMP, MMP

Table of content: TAMARA BURT LMP, MMP (NPI 1760515431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760515431 NPI number — TAMARA BURT LMP, MMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURT
Provider First Name:
TAMARA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP, MMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760515431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2735 HARBOR HEIGHTS LN E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-8104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-871-1324
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2475 BETHEL RD SE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-2490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-895-4844
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2007

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: 225700000X , with the licence number:  MA00017434 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MA00017434 . This is a "MASSAGE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0176265 . This is a "L&I NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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