Provider Demographics
NPI:1043469521
Name:PINE, DEBORAH SUZANNE (LMP)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:SUZANNE
Last Name:PINE
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 288
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-0288
Mailing Address - Country:US
Mailing Address - Phone:360-856-9007
Mailing Address - Fax:
Practice Address - Street 1:260 W MOORE ST
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-1039
Practice Address - Country:US
Practice Address - Phone:360-855-3000
Practice Address - Fax:360-856-3001
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00018718225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist