Provider Demographics
NPI:1326250218
Name:BLACKBIRD, MARLES (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARLES
Middle Name:
Last Name:BLACKBIRD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 12TH AVE SE
Mailing Address - Street 2:B-301
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2415
Mailing Address - Country:US
Mailing Address - Phone:360-705-9758
Mailing Address - Fax:360-943-8018
Practice Address - Street 1:1001 EASTSIDE ST SE
Practice Address - Street 2:SUITE C
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1608
Practice Address - Country:US
Practice Address - Phone:360-705-9758
Practice Address - Fax:360-705-9758
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007831171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor