Provider Demographics
NPI:1003179102
Name:GARRIS, DIANE (LMP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GARRIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16825 48TH AVE W
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-6401
Mailing Address - Country:US
Mailing Address - Phone:425-971-7878
Mailing Address - Fax:425-493-4348
Practice Address - Street 1:16825 48TH AVE W
Practice Address - Street 2:SUITE 330
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-6401
Practice Address - Country:US
Practice Address - Phone:425-971-7878
Practice Address - Fax:425-493-4348
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024091225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist