Provider Demographics
NPI:1376890863
Name:SHEVELAND, GWENDOLYN LEE (LMP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LEE
Last Name:SHEVELAND
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:LEE
Other - Last Name:ZIRN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1212 S. LLOYD ST.
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99212
Mailing Address - Country:US
Mailing Address - Phone:509-413-2097
Mailing Address - Fax:
Practice Address - Street 1:12929 E SPRAGUE AVE
Practice Address - Street 2:STE 104
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-0721
Practice Address - Country:US
Practice Address - Phone:509-891-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00020324225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 00020324OtherWASHINGTON DEPT. OF HEALTH MASSAGE PRACTITIONER LICENSE