Provider Demographics
NPI:1164736104
Name:CRYSALIS, LLC
Entity Type:Organization
Organization Name:CRYSALIS, LLC
Other - Org Name:CRYSALIS WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:REUST
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:206-407-3068
Mailing Address - Street 1:700 5TH AVE
Mailing Address - Street 2:SUITE 606
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-5058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 5TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3176
Practice Address - Country:US
Practice Address - Phone:206-407-3068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA111N00000X
133N00000X, 171100000X, 175F00000X
WAMA00005185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty