Provider Demographics
NPI:1518191147
Name:CANTRELL, MARLIE VIRGINIA (LMP)
Entity Type:Individual
Prefix:MS
First Name:MARLIE
Middle Name:VIRGINIA
Last Name:CANTRELL
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 1:12216 KAPOWSIN HIGHLANDS DR E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-6018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 N 26TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-5252
Practice Address - Country:US
Practice Address - Phone:253-683-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60034952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist