Provider Demographics
NPI:1043928716
Name:GIVENS, MARY RADENE (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RADENE
Last Name:GIVENS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 YAUGER WAY SW UNIT K201
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8349
Mailing Address - Country:US
Mailing Address - Phone:360-561-2288
Mailing Address - Fax:
Practice Address - Street 1:130 MARVIN RD SE STE 105
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6102
Practice Address - Country:US
Practice Address - Phone:360-939-1634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61354209225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist