Provider Demographics
NPI:1841595170
Name:WILSON, CHANTEL MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10202 PACIFIC AVE S., STE 215
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-6573
Mailing Address - Country:US
Mailing Address - Phone:253-332-8997
Mailing Address - Fax:253-531-8450
Practice Address - Street 1:10202 PACIFIC AVE S., STE 215
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-6573
Practice Address - Country:US
Practice Address - Phone:253-332-8997
Practice Address - Fax:253-531-8450
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00013633174400000X
WAMA00013633225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist