Provider Demographics
NPI:1538312830
Name:HAASE, MARY LOU (LMP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:HAASE
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:PO BOX 1758
Mailing Address - Street 2:129 GOLDENEYE STREET SW
Mailing Address - City:OCEAN SHORES
Mailing Address - State:WA
Mailing Address - Zip Code:98569-1758
Mailing Address - Country:US
Mailing Address - Phone:360-581-5368
Mailing Address - Fax:
Practice Address - Street 1:129 GOLDENEYE STREET SW
Practice Address - Street 2:
Practice Address - City:OCEAN SHORES
Practice Address - State:WA
Practice Address - Zip Code:98569
Practice Address - Country:US
Practice Address - Phone:360-581-5368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0190249OtherDEPARTMENT OF LABOR AND INDUSTRIES