Provider Demographics
NPI:1255659066
Name:GATEWAY THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:GATEWAY THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:ANDRE'A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-457-7374
Mailing Address - Street 1:118 N LIBERTY ST
Mailing Address - Street 2:STE A
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4322
Mailing Address - Country:US
Mailing Address - Phone:360-457-7374
Mailing Address - Fax:360-457-8717
Practice Address - Street 1:118 N LIBERTY ST
Practice Address - Street 2:STE A
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4322
Practice Address - Country:US
Practice Address - Phone:360-457-7374
Practice Address - Fax:360-457-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 00002207305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization