Provider Demographics
NPI:1649584798
Name:KOECKRITZ, MAILE D (LMP)
Entity Type:Individual
Prefix:
First Name:MAILE
Middle Name:D
Last Name:KOECKRITZ
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 1:1303 W 13TH AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-4069
Mailing Address - Country:US
Mailing Address - Phone:509-251-3355
Mailing Address - Fax:
Practice Address - Street 1:1303 W 13TH AVE APT 8
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4069
Practice Address - Country:US
Practice Address - Phone:509-251-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60154484225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist