Provider Demographics
NPI:1376784884
Name:LITTLE, MARY BRIDGET (LMT , LMP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRIDGET
Last Name:LITTLE
Suffix:
Gender:F
Credentials:LMT , LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 X ST
Mailing Address - Street 2:APT B4
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4159
Mailing Address - Country:US
Mailing Address - Phone:360-696-5587
Mailing Address - Fax:
Practice Address - Street 1:1321 X ST
Practice Address - Street 2:APT B4
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4159
Practice Address - Country:US
Practice Address - Phone:360-696-5587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00004775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist