Basic Information
| Provider Information | |||||||||
| NPI: | 1699328484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 NW GILMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980272446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254276562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 680 NW GILMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980272446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254276562 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2019 | ||||||||
| LastUpdateDate: | 07/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA60969179 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | MA60969179 | 01 | WA | WASHINGTON STATE MASSAGE LICENSE | OTHER |