Provider Demographics
NPI:1629102017
Name:WALLACE, BETSY KATRINA (LMP)
Entity Type:Individual
Prefix:MRS
First Name:BETSY
Middle Name:KATRINA
Last Name:WALLACE
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 1:9776 HOLMAN RD NW
Mailing Address - Street 2:109
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-2000
Mailing Address - Country:US
Mailing Address - Phone:206-782-8800
Mailing Address - Fax:
Practice Address - Street 1:9776 HOLMAN RD NW
Practice Address - Street 2:#109
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-2000
Practice Address - Country:US
Practice Address - Phone:206-782-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist