Provider Demographics
NPI:1629440011
Name:BEAUDETTE, MARY (LMP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BEAUDETTE
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 1:5430 W INTERURBAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6719
Mailing Address - Country:US
Mailing Address - Phone:425-877-1156
Mailing Address - Fax:
Practice Address - Street 1:10117 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3425
Practice Address - Country:US
Practice Address - Phone:425-806-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60598749172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist