Provider Demographics
NPI:1033416425
Name:RUSSELL, TASHA MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:MARIE
Last Name:RUSSELL
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:PO BOX 2462
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-2462
Mailing Address - Country:US
Mailing Address - Phone:360-687-3181
Mailing Address - Fax:360-687-1992
Practice Address - Street 1:15 SW 20TH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-3133
Practice Address - Country:US
Practice Address - Phone:360-687-3181
Practice Address - Fax:360-687-1992
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60171543225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist