Provider Demographics
NPI:1851410336
Name:RENEE, SALLY (LMP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:RENEE
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:PO BOX 1404
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368
Mailing Address - Country:US
Mailing Address - Phone:360-379-3322
Mailing Address - Fax:
Practice Address - Street 1:5437 CALIFORNIA AVE SW
Practice Address - Street 2:WHITE CRANE SPA
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136
Practice Address - Country:US
Practice Address - Phone:206-937-4777
Practice Address - Fax:206-937-2942
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00000697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist