Provider Demographics
NPI:1407491780
Name:MOWREY, DEREK (LMT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MOWREY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19206 SE 1ST ST STE 118
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7478
Mailing Address - Country:US
Mailing Address - Phone:360-433-9016
Mailing Address - Fax:360-433-9809
Practice Address - Street 1:19206 SE 1ST ST STE 118
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7478
Practice Address - Country:US
Practice Address - Phone:360-433-9016
Practice Address - Fax:360-433-9809
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60659177225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist