Provider Demographics
NPI:1093929671
Name:LIDREN, SARAH MAY (LMP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MAY
Last Name:LIDREN
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 1:4314 BECKONRIDGE DR W APT B
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-1369
Mailing Address - Country:US
Mailing Address - Phone:253-507-7569
Mailing Address - Fax:
Practice Address - Street 1:3211 56TH ST NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1359
Practice Address - Country:US
Practice Address - Phone:253-853-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023493225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist