Provider Demographics
NPI:1760512024
Name:MCLENNAN, MONICA R (LMP)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:R
Last Name:MCLENNAN
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 1:22735 ROCKWOOD LN SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-8994
Mailing Address - Country:US
Mailing Address - Phone:360-894-0633
Mailing Address - Fax:253-845-5753
Practice Address - Street 1:11108 WOODLAND AVE E STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5893
Practice Address - Country:US
Practice Address - Phone:253-845-5358
Practice Address - Fax:253-845-5753
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019245225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0191753OtherLABOR & INDUSTRIES
WAMA00019245OtherWA MASSAGE LICENSE