Provider Demographics
NPI:1750045332
Name:KELLIHER, SPENCER G (LMT)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:G
Last Name:KELLIHER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 ROCKEFELLER AVE APT B
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2254
Mailing Address - Country:US
Mailing Address - Phone:425-231-7605
Mailing Address - Fax:
Practice Address - Street 1:404 91ST AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-2567
Practice Address - Country:US
Practice Address - Phone:425-231-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61234383225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA61234383OtherLICENSED MASSAGE THERAPIST