Provider Demographics
NPI:1114390762
Name:METAMORPHIC MASSAGE & WELLNESS INC
Entity Type:Organization
Organization Name:METAMORPHIC MASSAGE & WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HERRON
Authorized Official - Suffix:
Authorized Official - Credentials:LMP, MMP
Authorized Official - Phone:360-520-3011
Mailing Address - Street 1:6342 LITTLEROCK RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7332
Mailing Address - Country:US
Mailing Address - Phone:360-520-3011
Mailing Address - Fax:
Practice Address - Street 1:6342 LITTLEROCK RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7332
Practice Address - Country:US
Practice Address - Phone:360-520-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022554305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization