Provider Demographics
NPI:1528211471
Name:RAY, DIANE K (LMP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:RAY
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 1:8126 LENA LN
Mailing Address - Street 2:
Mailing Address - City:CONCRETE
Mailing Address - State:WA
Mailing Address - Zip Code:98237-9303
Mailing Address - Country:US
Mailing Address - Phone:360-770-4530
Mailing Address - Fax:360-826-4567
Practice Address - Street 1:639 SUNSET PARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-1540
Practice Address - Country:US
Practice Address - Phone:360-770-4530
Practice Address - Fax:360-826-4567
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60040596225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist