Provider Demographics
NPI:1033354824
Name:NORTHCOTT, KYLE ALLEN (LMT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ALLEN
Last Name:NORTHCOTT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1273
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:WA
Mailing Address - Zip Code:98862-1220
Mailing Address - Country:US
Mailing Address - Phone:509-996-4462
Mailing Address - Fax:
Practice Address - Street 1:105 NORFOLK RD
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:WA
Practice Address - Zip Code:98862
Practice Address - Country:US
Practice Address - Phone:509-996-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00022316225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist