Basic Information
Provider Information
NPI: 1003014978
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MILLER
FirstName: MELISSA
MiddleName: JEAN
NamePrefix:  
NameSuffix:  
Credential: LMP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1408 WHITMAN ST NE
Address2:  
City: TACOMA
State: WA
PostalCode: 984221058
CountryCode: US
TelephoneNumber: 2064277912
FaxNumber:  
Practice Location
Address1: 914 D ST NE STE 101
Address2:  
City: AUBURN
State: WA
PostalCode: 980024163
CountryCode: US
TelephoneNumber: 2539390906
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/03/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000XMA00019851WAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


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