Provider Demographics
NPI:1124565643
Name:LOVE, ELEKTRA ATHENA
Entity Type:Individual
Prefix:
First Name:ELEKTRA
Middle Name:ATHENA
Last Name:LOVE
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 1:2728 61ST AVE SW
Mailing Address - Street 2:APT 10
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4700
Mailing Address - Country:US
Mailing Address - Phone:425-293-7129
Mailing Address - Fax:
Practice Address - Street 1:2728 61ST AVE SW
Practice Address - Street 2:APT 10
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4700
Practice Address - Country:US
Practice Address - Phone:425-293-7129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-22
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60727162225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist