Provider Demographics
NPI:1104179290
Name:SMITH, ELIZABETH DAWN (LMP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:DAWN
Other - Last Name:EDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:4418 S 170TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98188-3252
Mailing Address - Country:US
Mailing Address - Phone:206-661-6053
Mailing Address - Fax:
Practice Address - Street 1:4418 S 170TH ST
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98188-3252
Practice Address - Country:US
Practice Address - Phone:206-661-6053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60217697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist