Provider Demographics
NPI:1336462472
Name:BOONYARUTTAPUN, WACHIRABOON (CMT)
Entity Type:Individual
Prefix:
First Name:WACHIRABOON
Middle Name:
Last Name:BOONYARUTTAPUN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8087 JANNA LEE AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-3811
Mailing Address - Country:US
Mailing Address - Phone:703-477-6700
Mailing Address - Fax:
Practice Address - Street 1:8087 JANNA LEE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-3811
Practice Address - Country:US
Practice Address - Phone:703-477-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019004737225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist