Provider Demographics
NPI:1649589961
Name:BURNHAM, GRACE E (LMP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:BURNHAM
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 1:2500 SW TRENTON ST
Mailing Address - Street 2:404
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-3268
Mailing Address - Country:US
Mailing Address - Phone:206-755-0555
Mailing Address - Fax:
Practice Address - Street 1:2500 SW TRENTON ST
Practice Address - Street 2:404
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-3268
Practice Address - Country:US
Practice Address - Phone:206-755-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60139440225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist