Provider Demographics
NPI:1437300167
Name:SWETZ, FAE ELLEN (LMP)
Entity Type:Individual
Prefix:
First Name:FAE
Middle Name:ELLEN
Last Name:SWETZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11703 212TH ST E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-6483
Mailing Address - Country:US
Mailing Address - Phone:253-212-7290
Mailing Address - Fax:
Practice Address - Street 1:2115 S 56TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-6902
Practice Address - Country:US
Practice Address - Phone:253-235-2740
Practice Address - Fax:253-475-0588
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60037457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist