Provider Demographics
NPI:1083816847
Name:KVASOV, MARINA AFANASEVNA (LMP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:AFANASEVNA
Last Name:KVASOV
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 14001
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99214
Mailing Address - Country:US
Mailing Address - Phone:509-389-7584
Mailing Address - Fax:509-777-2227
Practice Address - Street 1:100 N MULLAN
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206
Practice Address - Country:US
Practice Address - Phone:509-777-2225
Practice Address - Fax:509-777-2227
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA395744-00OtherNCBTMB CERTIFICATE
WAMA00018933OtherMASSAGE LICENSE