Basic Information
| Provider Information | |||||||||
| NPI: | 1336201003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | MIRA | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 914 D ST NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980024163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539390906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 914 D ST NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980024163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539390906 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00016282 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.