Provider Demographics
NPI:1063843134
Name:COFFEE, MARY CATHERINE (LMP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
Last Name:COFFEE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:COFFEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:3595 NW BUCKLIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8503
Mailing Address - Country:US
Mailing Address - Phone:360-698-3140
Mailing Address - Fax:
Practice Address - Street 1:3595 NW BUCKLIN HILL RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8503
Practice Address - Country:US
Practice Address - Phone:360-698-3140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60404484225700000X
COMT 0006544225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist