Provider Demographics
NPI:1356469548
Name:CHRISTIANSEN, CAROLYN MICHELE (LMP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MICHELE
Last Name:CHRISTIANSEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:C.
Other - Middle Name:MICHELE
Other - Last Name:CHRISTIANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98353-0772
Mailing Address - Country:US
Mailing Address - Phone:360-440-8060
Mailing Address - Fax:
Practice Address - Street 1:450 PORT ORCHARD BLVD STE 390
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4705
Practice Address - Country:US
Practice Address - Phone:360-440-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012895225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist