Provider Demographics
NPI:1356656888
Name:VAN DEREN, SARAH ROSE (LMP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ROSE
Last Name:VAN DEREN
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 1:39504 EATONVL CTOF RD E
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-9002
Mailing Address - Country:US
Mailing Address - Phone:253-320-3142
Mailing Address - Fax:
Practice Address - Street 1:824 S 28TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-8105
Practice Address - Country:US
Practice Address - Phone:253-320-3142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60110966225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist