Provider Demographics
NPI:1760840748
Name:COULTER, REVA KATHRYN
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:KATHRYN
Last Name:COULTER
Suffix:
Gender:F
Credentials:
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 5859
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-5859
Mailing Address - Country:US
Mailing Address - Phone:360-438-1998
Mailing Address - Fax:360-438-3524
Practice Address - Street 1:719 SLEATER KINNEY RD SE STE 130
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1138
Practice Address - Country:US
Practice Address - Phone:360-438-1998
Practice Address - Fax:360-438-3524
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist