Provider Demographics
NPI:1710306022
Name:HALVORSON, THOMAS BENJAMIN (LMP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BENJAMIN
Last Name:HALVORSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3933 S 302ND ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2225
Mailing Address - Country:US
Mailing Address - Phone:253-380-2685
Mailing Address - Fax:
Practice Address - Street 1:5609 S LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5319
Practice Address - Country:US
Practice Address - Phone:253-380-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60457447390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60457447OtherWASINGTON STATE MASSAGE LICENCE