Provider Demographics
NPI:1053461814
Name:FORTMAN, DEBORAH DIANE
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:DIANE
Last Name:FORTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBBIE
Other - Middle Name:MOSS
Other - Last Name:FORTMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:118 N LEWIS ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1516
Mailing Address - Country:US
Mailing Address - Phone:425-879-5111
Mailing Address - Fax:360-794-5907
Practice Address - Street 1:118 N LEWIS ST
Practice Address - Street 2:SUITE 113
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1516
Practice Address - Country:US
Practice Address - Phone:425-879-5111
Practice Address - Fax:360-794-5907
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014147225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist