Provider Demographics
NPI:1164803250
Name:HINES, PETRA (LMP)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:HINES
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 1:2102 N ALDER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-6637
Mailing Address - Country:US
Mailing Address - Phone:253-759-2300
Mailing Address - Fax:253-759-2333
Practice Address - Street 1:2102 N ALDER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406
Practice Address - Country:US
Practice Address - Phone:253-878-1302
Practice Address - Fax:253-759-2333
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008928225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist