Provider Demographics
NPI:1518263730
Name:DUTTON, LARRA (LMP, CLT)
Entity Type:Individual
Prefix:MS
First Name:LARRA
Middle Name:
Last Name:DUTTON
Suffix:
Gender:F
Credentials:LMP, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 PHINNEY AVE N APT 1
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5855
Mailing Address - Country:US
Mailing Address - Phone:206-601-9994
Mailing Address - Fax:
Practice Address - Street 1:2366 EASTLAKE AVE E STE 217
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-6501
Practice Address - Country:US
Practice Address - Phone:206-601-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60205863172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist