Provider Demographics
NPI:1003351909
Name:EMERSON, SERENA (LAC)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:EMERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2582 ISLAND VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LUMMI ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98262-8631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2582 ISLAND VIEW LN
Practice Address - Street 2:
Practice Address - City:LUMMI ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98262-8631
Practice Address - Country:US
Practice Address - Phone:360-519-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
WAMA60387889225700000X
WAAC60694145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist