Provider Demographics
NPI:1104215730
Name:GORSLINE, KAITLIN DAWN
Entity Type:Individual
Prefix:MISS
First Name:KAITLIN
Middle Name:DAWN
Last Name:GORSLINE
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 1:812 12TH AVE SE
Mailing Address - Street 2:APT P5
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4969
Mailing Address - Country:US
Mailing Address - Phone:253-282-2533
Mailing Address - Fax:
Practice Address - Street 1:202 S 348TH ST
Practice Address - Street 2:#4
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7070
Practice Address - Country:US
Practice Address - Phone:253-874-2498
Practice Address - Fax:253-248-1909
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60484304225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist