Provider Demographics
NPI:1689742264
Name:MICHAELIS, ROBERTA (LMP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:MICHAELIS
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 1:12128 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1905
Mailing Address - Country:US
Mailing Address - Phone:509-999-5939
Mailing Address - Fax:509-466-8606
Practice Address - Street 1:1111 E WESTVIEW CT
Practice Address - Street 2:SUITE A
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1376
Practice Address - Country:US
Practice Address - Phone:509-999-5939
Practice Address - Fax:509-466-8606
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist