Provider Demographics
NPI:1225254873
Name:ACTIVE HEALING MASSAGE THERAPY
Entity Type:Organization
Organization Name:ACTIVE HEALING MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WIKAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:360-357-3009
Mailing Address - Street 1:6995 LITTLEROCK RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7246
Mailing Address - Country:US
Mailing Address - Phone:360-357-3009
Mailing Address - Fax:
Practice Address - Street 1:6995 LITTLEROCK RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7246
Practice Address - Country:US
Practice Address - Phone:360-357-3009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty