Provider Demographics
NPI:1821540733
Name:KANNEGAARD, MAVERICK
Entity Type:Individual
Prefix:
First Name:MAVERICK
Middle Name:
Last Name:KANNEGAARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 NE 94TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2730
Mailing Address - Country:US
Mailing Address - Phone:208-874-7648
Mailing Address - Fax:
Practice Address - Street 1:FREMONT AVE N #412
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103
Practice Address - Country:US
Practice Address - Phone:206-853-1540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60332657225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist