Provider Demographics
NPI:1437308319
Name:BLUMBERG, REBECCA JANE (LMP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:BLUMBERG
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 1:44 DWINELL RD
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-9524
Mailing Address - Country:US
Mailing Address - Phone:360-470-3388
Mailing Address - Fax:
Practice Address - Street 1:304 W MAIN
Practice Address - Street 2:STE 8
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-470-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021964225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0211408OtherLABOR & INDUSTRIES