Provider Demographics
NPI:1033412986
Name:BERNETHY, LORI (LMP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BERNETHY
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 1:1101 AVENUE D
Mailing Address - Street 2:SUITE D103
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2083
Mailing Address - Country:US
Mailing Address - Phone:360-568-2686
Mailing Address - Fax:360-862-8016
Practice Address - Street 1:1101 AVENUE D
Practice Address - Street 2:SUITE D103
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2083
Practice Address - Country:US
Practice Address - Phone:360-568-2686
Practice Address - Fax:360-862-8016
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist