Provider Demographics
NPI:1346777489
Name:THOMPSON, TRACI ELLEN (LMP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:ELLEN
Last Name:THOMPSON
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 1:3813 SW HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3459
Mailing Address - Country:US
Mailing Address - Phone:360-434-3604
Mailing Address - Fax:
Practice Address - Street 1:3514 FREMONT AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8814
Practice Address - Country:US
Practice Address - Phone:206-634-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist