Provider Demographics
NPI:1063639367
Name:ANDERSON, CAROLYN SUE (LMP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
Last Name:ANDERSON
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 2353
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-2353
Mailing Address - Country:US
Mailing Address - Phone:360-698-2198
Mailing Address - Fax:
Practice Address - Street 1:8243 KNUTE LN NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8512
Practice Address - Country:US
Practice Address - Phone:360-698-2198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5472225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist