Provider Demographics
NPI:1609411388
Name:RICKARDS, TYRSA JEAN
Entity Type:Individual
Prefix:
First Name:TYRSA
Middle Name:JEAN
Last Name:RICKARDS
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 1:907 N OLD NELSON RD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-9025
Mailing Address - Country:US
Mailing Address - Phone:760-405-7237
Mailing Address - Fax:
Practice Address - Street 1:228 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7821
Practice Address - Country:US
Practice Address - Phone:360-457-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60993416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist