Provider Demographics
NPI:1376831305
Name:KALITOVIC, WESLEY C (LMP)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:C
Last Name:KALITOVIC
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 1:1309 39TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4806
Mailing Address - Country:US
Mailing Address - Phone:425-218-9753
Mailing Address - Fax:
Practice Address - Street 1:1800 BICKFORD AVE STE 201
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-1769
Practice Address - Country:US
Practice Address - Phone:425-319-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60214967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist