Provider Demographics
NPI:1831456912
Name:DAVIDSON, MARY ISABELL (LMP,LA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ISABELL
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LMP,LA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 BELLEVUE WAY NE
Mailing Address - Street 2:SUITE # 14
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5721
Mailing Address - Country:US
Mailing Address - Phone:425-462-1116
Mailing Address - Fax:
Practice Address - Street 1:2110 116TH AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3040
Practice Address - Country:US
Practice Address - Phone:425-462-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist