Provider Demographics
NPI:1164704771
Name:METAYER, TINA MAE (LMP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MAE
Last Name:METAYER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8621 MARTIN WAY E STE A102
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5855
Mailing Address - Country:US
Mailing Address - Phone:360-456-4954
Mailing Address - Fax:
Practice Address - Street 1:8621 MARTIN WAY E STE A102
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5855
Practice Address - Country:US
Practice Address - Phone:360-456-4954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60241023225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist