Provider Demographics
NPI:1073679395
Name:TAHLEQUAH, MARY JEAN (LMP,COMP,CNMT,SI)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JEAN
Last Name:TAHLEQUAH
Suffix:
Gender:F
Credentials:LMP,COMP,CNMT,SI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27615 108TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-8768
Mailing Address - Country:US
Mailing Address - Phone:253-850-2333
Mailing Address - Fax:253-850-7164
Practice Address - Street 1:27615 108TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-8768
Practice Address - Country:US
Practice Address - Phone:253-850-2333
Practice Address - Fax:253-850-7164
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00010308OtherMASSAGE LIC #