Provider Demographics
NPI:1275835779
Name:KNUTH, KIM DENISE (LMP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DENISE
Last Name:KNUTH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16111 SE MCGILLIVRAY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9033
Mailing Address - Country:US
Mailing Address - Phone:360-254-0994
Mailing Address - Fax:360-254-0930
Practice Address - Street 1:16111 SE MCGILLIVRAY BLVD STE A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-254-0994
Practice Address - Fax:360-254-0930
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00025369225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist