Provider Demographics
NPI:1083778104
Name:GEDEVANISHVILI, MARIAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:GEDEVANISHVILI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18622 SE 265TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-8421
Mailing Address - Country:US
Mailing Address - Phone:206-755-1758
Mailing Address - Fax:253-883-2686
Practice Address - Street 1:10700 SE 208TH ST STE 207
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-5545
Practice Address - Country:US
Practice Address - Phone:206-755-1758
Practice Address - Fax:253-833-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 2255A2300X
WAMA60058598225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer