Provider Demographics
NPI:1417324997
Name:WHITEHEAD, MARY (ND, LMP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:ND, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6830 NE BOTHELL WAY # C-105
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-3546
Mailing Address - Country:US
Mailing Address - Phone:704-577-1532
Mailing Address - Fax:
Practice Address - Street 1:6830 NE BOTHELL WAY # C-105
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-3546
Practice Address - Country:US
Practice Address - Phone:704-577-1532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60236962225700000X
WANT60796387175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist