Provider Demographics
NPI:1609456094
Name:AVILA, SAMANTHA (MA60886820)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:MA60886820
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 NE 4TH ST APT G306
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-8814
Mailing Address - Country:US
Mailing Address - Phone:702-750-8348
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:425-249-7705
Practice Address - Fax:425-321-5508
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60886820225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist