Provider Demographics
NPI:1356657472
Name:WALL, MICHAEL (LMP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13002 81ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2546
Mailing Address - Country:US
Mailing Address - Phone:425-417-4123
Mailing Address - Fax:
Practice Address - Street 1:18920 BOTHELL WAY NE
Practice Address - Street 2:#204
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1981
Practice Address - Country:US
Practice Address - Phone:425-424-3730
Practice Address - Fax:425-424-2371
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60163284225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist