Provider Demographics
NPI:1801379920
Name:MCKNEW, MINDY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LYNN
Last Name:MCKNEW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 SE SPENCER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-7082
Mailing Address - Country:US
Mailing Address - Phone:360-535-0796
Mailing Address - Fax:
Practice Address - Street 1:1800 SE MILE HILL DR STE 150
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3517
Practice Address - Country:US
Practice Address - Phone:360-874-0232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60735447225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty