Provider Demographics
NPI:1629354816
Name:IDE, GEORGIA ANNE (LMP)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:ANNE
Last Name:IDE
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 1:20229 150TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9132
Mailing Address - Country:US
Mailing Address - Phone:425-786-3086
Mailing Address - Fax:
Practice Address - Street 1:12951 BEL RED RD STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2628
Practice Address - Country:US
Practice Address - Phone:425-786-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60247950225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist