Provider Demographics
NPI:1184842320
Name:RUBLAITUS, TANYA KATHLEEN (LMP)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:KATHLEEN
Last Name:RUBLAITUS
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 1:3105 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-4739
Mailing Address - Country:US
Mailing Address - Phone:360-301-2934
Mailing Address - Fax:
Practice Address - Street 1:3105 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-4739
Practice Address - Country:US
Practice Address - Phone:360-301-2934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023760225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist