Provider Demographics
NPI:1043510753
Name:WHITE, BOBBY (LMP)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22906 39TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRIER
Mailing Address - State:WA
Mailing Address - Zip Code:98036-8281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6515 132ND AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-8628
Practice Address - Country:US
Practice Address - Phone:425-822-4326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60173939225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist