Provider Demographics
NPI:1194198614
Name:WATERSHED WELLNESS LLC
Entity Type:Organization
Organization Name:WATERSHED WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / ACUPUNCTURIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:KULHAWIK-HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:EAMP, MACOM, NTP
Authorized Official - Phone:360-350-0773
Mailing Address - Street 1:703 LILLY RD NE
Mailing Address - Street 2:STE 102
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5191
Mailing Address - Country:US
Mailing Address - Phone:360-350-0773
Mailing Address - Fax:360-350-0723
Practice Address - Street 1:703 LILLY RD NE
Practice Address - Street 2:STE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5191
Practice Address - Country:US
Practice Address - Phone:360-350-0773
Practice Address - Fax:360-350-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60065363171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty