Provider Demographics
NPI:1003385337
Name:LEEPER, MITZY DANAE (LMT, TTT)
Entity Type:Individual
Prefix:
First Name:MITZY
Middle Name:DANAE
Last Name:LEEPER
Suffix:
Gender:F
Credentials:LMT, TTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7812 NE 124TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-4146
Mailing Address - Country:US
Mailing Address - Phone:360-772-1740
Mailing Address - Fax:
Practice Address - Street 1:613 E MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3358
Practice Address - Country:US
Practice Address - Phone:360-772-1740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist