Provider Demographics
NPI:1366825424
Name:WHITE, TIA RICHELLE (LMP)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:RICHELLE
Last Name:WHITE
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 1:1905 SE 158TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9065
Mailing Address - Country:US
Mailing Address - Phone:360-608-3429
Mailing Address - Fax:
Practice Address - Street 1:1905 SE 158TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9065
Practice Address - Country:US
Practice Address - Phone:360-608-3429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60542566225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist