Provider Demographics
NPI:1093842163
Name:BEATY, DEBRA JO (LMT, LMP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO
Last Name:BEATY
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 NE 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6761
Mailing Address - Country:US
Mailing Address - Phone:360-931-3591
Mailing Address - Fax:
Practice Address - Street 1:120 NE 117TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5020
Practice Address - Country:US
Practice Address - Phone:360-931-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA024201MA00017686225700000X
OR10306225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist