Provider Demographics
NPI:1417237744
Name:ERICKSON-ENSSLIN, KAREN DIANE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:DIANE
Last Name:ERICKSON-ENSSLIN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:KAREN
Other - Middle Name:DIANE
Other - Last Name:BRUNSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2311 1/2 QUEETS AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOQUIAM
Mailing Address - State:WA
Mailing Address - Zip Code:98550
Mailing Address - Country:US
Mailing Address - Phone:360-581-7329
Mailing Address - Fax:
Practice Address - Street 1:601 S. BOONE STREET
Practice Address - Street 2:SUITE #2
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-581-7329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019289225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist