Provider Demographics
NPI:1497187611
Name:PUYALLUP INTEGRATIVE MASSAGE LLC
Entity Type:Organization
Organization Name:PUYALLUP INTEGRATIVE MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RESSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:253-370-4223
Mailing Address - Street 1:823 W MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-1151
Mailing Address - Country:US
Mailing Address - Phone:253-268-0078
Mailing Address - Fax:253-446-6681
Practice Address - Street 1:823 W MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1151
Practice Address - Country:US
Practice Address - Phone:253-268-0078
Practice Address - Fax:253-446-6681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009118225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty