Provider Demographics
NPI:1154086593
Name:THELEN, SAMARA R (MA)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:R
Last Name:THELEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:219 JEWELL ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-7329
Mailing Address - Country:US
Mailing Address - Phone:253-350-3833
Mailing Address - Fax:253-350-3833
Practice Address - Street 1:709 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3419
Practice Address - Country:US
Practice Address - Phone:253-350-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022106225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist