Provider Demographics
NPI:1700397452
Name:MCKELVEY, MEAGEN MICHELLE (LMP)
Entity Type:Individual
Prefix:MS
First Name:MEAGEN
Middle Name:MICHELLE
Last Name:MCKELVEY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:MEAGEN
Other - Middle Name:MICHELLE
Other - Last Name:MUNROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:1129 W MAIN ST STE 172
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2034
Mailing Address - Country:US
Mailing Address - Phone:360-863-0960
Mailing Address - Fax:425-320-3880
Practice Address - Street 1:1129 W MAIN ST STE 172
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2034
Practice Address - Country:US
Practice Address - Phone:360-863-0960
Practice Address - Fax:425-320-3880
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-21
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015970225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist