Provider Demographics
NPI:1760103212
Name:MCCAFFERTY, MICKY SHANE (LMT)
Entity Type:Individual
Prefix:
First Name:MICKY
Middle Name:SHANE
Last Name:MCCAFFERTY
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 1:4000 NE 109TH AVE UNIT 95
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5721
Mailing Address - Country:US
Mailing Address - Phone:360-989-7331
Mailing Address - Fax:
Practice Address - Street 1:501 E MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3356
Practice Address - Country:US
Practice Address - Phone:360-831-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26877225700000X
WAMA61408846225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist