Provider Demographics
NPI:1063677375
Name:MCCALLON, KATRINA ALENE (LMP)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:ALENE
Last Name:MCCALLON
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 1:14410 SE PETROVITSKY RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058
Mailing Address - Country:US
Mailing Address - Phone:425-282-5545
Mailing Address - Fax:
Practice Address - Street 1:14410 SE PETROVITSKY RD
Practice Address - Street 2:SUITE 209
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:425-282-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011506225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist