Provider Demographics
NPI:1164565701
Name:POULIOT, DICK DUANE (LMP)
Entity Type:Individual
Prefix:
First Name:DICK
Middle Name:DUANE
Last Name:POULIOT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10218 60TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-1016
Mailing Address - Country:US
Mailing Address - Phone:425-280-1008
Mailing Address - Fax:
Practice Address - Street 1:1818 GROVE ST # A
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4330
Practice Address - Country:US
Practice Address - Phone:425-280-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAM00004930225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA54890OtherL&I NUMBER
WAPO9881OtherREGENCE BLUE SHIELD NUM.