Provider Demographics
NPI:1508110537
Name:RISTINE, MARY DENISE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DENISE
Last Name:RISTINE
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 1:5274 35TH ST E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2129
Mailing Address - Country:US
Mailing Address - Phone:253-304-6810
Mailing Address - Fax:
Practice Address - Street 1:5274 35TH ST E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-2129
Practice Address - Country:US
Practice Address - Phone:253-304-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60311860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist