Provider Demographics
NPI:1033360755
Name:LARSON, MIKI (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MIKI
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9414 RIDGE TOP BLVD
Mailing Address - Street 2:#103
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383
Mailing Address - Country:US
Mailing Address - Phone:360-434-1051
Mailing Address - Fax:360-437-2345
Practice Address - Street 1:1101 SUPER MALL WAY
Practice Address - Street 2:#1269
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001
Practice Address - Country:US
Practice Address - Phone:253-269-0261
Practice Address - Fax:253-269-0202
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMA00025170225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA230529OtherWA ST. DEPT OF LABOR & INDUSTRIES