Provider Demographics
NPI:1578027330
Name:GENT, LATISHA MARIE (MA60898240)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:MARIE
Last Name:GENT
Suffix:
Gender:F
Credentials:MA60898240
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28413 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3237
Mailing Address - Country:US
Mailing Address - Phone:253-961-6569
Mailing Address - Fax:
Practice Address - Street 1:200 S TOBIN ST STE A
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5338
Practice Address - Country:US
Practice Address - Phone:425-243-7705
Practice Address - Fax:425-321-5508
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60898240225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist