Provider Demographics
NPI:1164733077
Name:ROBERTS, MICHELLE RENE (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENE
Last Name:ROBERTS
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 1:10620 NE 8TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4380
Mailing Address - Country:US
Mailing Address - Phone:425-999-9633
Mailing Address - Fax:
Practice Address - Street 1:10620 NE 8TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4380
Practice Address - Country:US
Practice Address - Phone:425-999-9633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60142021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist