Provider Demographics
NPI:1154645869
Name:DEPUTY CROFOOT, REBECCA (LMP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:DEPUTY CROFOOT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:DEPUTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:822 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033
Mailing Address - Country:US
Mailing Address - Phone:425-889-1403
Mailing Address - Fax:425-889-1405
Practice Address - Street 1:822 6TH ST S
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033
Practice Address - Country:US
Practice Address - Phone:425-889-1403
Practice Address - Fax:425-889-1405
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0261420OtherLABOR AND INDUSTRIES
WA162824OtherLABOR AND INDUSTRIES