Provider Demographics
NPI:1235534819
Name:SAMUELS, BRUCE CAREY (MA60334921)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CAREY
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:MA60334921
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ALPS RD
Mailing Address - Street 2:UNIT 1030
Mailing Address - City:MOXEE
Mailing Address - State:WA
Mailing Address - Zip Code:98936-9517
Mailing Address - Country:US
Mailing Address - Phone:509-910-5903
Mailing Address - Fax:
Practice Address - Street 1:300 ALPS RD
Practice Address - Street 2:UNIT 1030
Practice Address - City:MOXEE
Practice Address - State:WA
Practice Address - Zip Code:98936-9517
Practice Address - Country:US
Practice Address - Phone:509-910-5903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60334921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist