Provider Demographics
NPI:1790834653
Name:GROBE, MYSTIQUE D (ND,LAC)
Entity Type:Individual
Prefix:DR
First Name:MYSTIQUE
Middle Name:D
Last Name:GROBE
Suffix:
Gender:F
Credentials:ND,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 COHO WAY
Mailing Address - Street 2:#309
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2067
Mailing Address - Country:US
Mailing Address - Phone:360-527-2812
Mailing Address - Fax:360-734-3088
Practice Address - Street 1:851 COHO WAY
Practice Address - Street 2:#309
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2067
Practice Address - Country:US
Practice Address - Phone:360-527-2812
Practice Address - Fax:360-734-3088
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00000225171100000X
WANT00000713175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
912061822OtherFED TAX ID
WAAC00000225OtherSTATE LICENSE
WANT00000713OtherSTATE LICENSE