Provider Demographics
NPI:1073638177
Name:KISSELEV, MIKHAIL (ND, LMP)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:KISSELEV
Suffix:
Gender:M
Credentials:ND, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11524 15TH AVE NE STE C
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6357
Mailing Address - Country:US
Mailing Address - Phone:206-355-9740
Mailing Address - Fax:206-361-0636
Practice Address - Street 1:11524 15TH AVE NE STE C
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6357
Practice Address - Country:US
Practice Address - Phone:206-355-9740
Practice Address - Fax:206-361-0636
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001520175F00000X
WAMA00013915225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0200908OtherL&I