Provider Demographics
NPI:1730458001
Name:SMITH, TINA (LMP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SMITH
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 2645
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-7125
Mailing Address - Country:US
Mailing Address - Phone:360-378-3637
Mailing Address - Fax:360-378-3637
Practice Address - Street 1:440 SPRING STREET
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-7125
Practice Address - Country:US
Practice Address - Phone:360-378-3637
Practice Address - Fax:360-378-3637
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist