Provider Demographics
NPI:1033648142
Name:CHAMBERLAIN, ANTHONY TODD (MA 60201222)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TODD
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:MA 60201222
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8190 ROAD R.7 SE
Mailing Address - Street 2:
Mailing Address - City:WARDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98857-9596
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1053
Practice Address - Country:US
Practice Address - Phone:509-488-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60201222225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist