Provider Demographics
NPI:1437690039
Name:TAVARES, CARRIE A (LMP)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:A
Last Name:TAVARES
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:A
Other - Last Name:TAVARES,LMT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:6822 279TH ST NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-6041
Mailing Address - Country:US
Mailing Address - Phone:206-660-8500
Mailing Address - Fax:
Practice Address - Street 1:9623 32ND ST SE STE 117&118
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-5779
Practice Address - Country:US
Practice Address - Phone:206-660-8500
Practice Address - Fax:425-320-4091
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012196225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604525883OtherLAKESIDE MASSAGE AND WELLNESS STUDIO