Provider Demographics
NPI:1558842336
Name:CHANG, PHAVANA
Entity Type:Individual
Prefix:
First Name:PHAVANA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9628 25TH DR SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-2927
Mailing Address - Country:US
Mailing Address - Phone:425-350-4020
Mailing Address - Fax:
Practice Address - Street 1:2003 132ND ST SE STE E
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-7140
Practice Address - Country:US
Practice Address - Phone:425-379-6301
Practice Address - Fax:425-379-5761
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60330324225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist