Provider Demographics
NPI:1033522057
Name:MONROE THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:MONROE THERAPEUTIC MASSAGE
Other - Org Name:MICROSOFT LIVING WELL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-863-0642
Mailing Address - Street 1:101 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1519
Mailing Address - Country:US
Mailing Address - Phone:360-863-0642
Mailing Address - Fax:
Practice Address - Street 1:3925 159TH AVE NE
Practice Address - Street 2:BUILDING 21
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052
Practice Address - Country:US
Practice Address - Phone:425-455-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013939225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty