Provider Demographics
NPI:1790499440
Name:MARTIN, LORESSA BETH (MA61343683)
Entity Type:Individual
Prefix:
First Name:LORESSA
Middle Name:BETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA61343683
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PROTECTION PL
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-9331
Mailing Address - Country:US
Mailing Address - Phone:530-386-4767
Mailing Address - Fax:
Practice Address - Street 1:603 E 8TH ST STE D
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6251
Practice Address - Country:US
Practice Address - Phone:360-504-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61343683225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist