Provider Demographics
NPI:1073012233
Name:SHUSTOV, MARIAN ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:ELIZABETH
Last Name:SHUSTOV
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 1:3054 255TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9436
Mailing Address - Country:US
Mailing Address - Phone:425-922-3774
Mailing Address - Fax:
Practice Address - Street 1:3054 255TH AVE SE
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9436
Practice Address - Country:US
Practice Address - Phone:425-922-3774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60715760225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist