Provider Demographics
NPI:1043385438
Name:MADLUNG, COURTNEY JANELLE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:JANELLE
Last Name:MADLUNG
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 1:15324 MAIN ST E STE B
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-2698
Mailing Address - Country:US
Mailing Address - Phone:253-863-5323
Mailing Address - Fax:253-863-2034
Practice Address - Street 1:15324 MAIN ST E STE B
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-2698
Practice Address - Country:US
Practice Address - Phone:253-863-5323
Practice Address - Fax:253-863-2034
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019055225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1580839OtherGROUP TAX ID#
WA602414363OtherTAX ID#
WAMA00019055OtherWA LICENSE CREDENTIAL#
WA183864OtherINT'L MASSAGE ASSOC#