Provider Demographics
NPI:1508115940
Name:MICHELLE DRAGOO LMP
Entity Type:Organization
Organization Name:MICHELLE DRAGOO LMP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAGOO
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-721-5195
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-0214
Mailing Address - Country:US
Mailing Address - Phone:360-721-5195
Mailing Address - Fax:360-887-2984
Practice Address - Street 1:414 PIONEER ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-4512
Practice Address - Country:US
Practice Address - Phone:360-721-5195
Practice Address - Fax:360-887-2984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014675225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0190344OtherWASHINGTON LABOR AND INDUSTRIES