Provider Demographics
NPI:1679700827
Name:MOEN, SPRING MECHIAEL (LMP)
Entity Type:Individual
Prefix:
First Name:SPRING
Middle Name:MECHIAEL
Last Name:MOEN
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:PO BOX 4007
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-4007
Mailing Address - Country:US
Mailing Address - Phone:360-692-5577
Mailing Address - Fax:360-692-3720
Practice Address - Street 1:10315 SILVERDALE WAY NW # D4
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7670
Practice Address - Country:US
Practice Address - Phone:360-692-5577
Practice Address - Fax:360-692-3720
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60012558225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist