Provider Demographics
NPI:1235980210
Name:RIVERSTONE, GREY LUNA JACK
Entity Type:Individual
Prefix:
First Name:GREY
Middle Name:LUNA JACK
Last Name:RIVERSTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:SACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:21040 NE WOODINVILLE DUVALL RD
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98077-7748
Mailing Address - Country:US
Mailing Address - Phone:425-505-7747
Mailing Address - Fax:
Practice Address - Street 1:16398 NE 85TH ST STE 100
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3555
Practice Address - Country:US
Practice Address - Phone:425-636-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023063225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist