Provider Demographics
NPI:1851638175
Name:LARSON, MELISSA IRENE (LMP)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:IRENE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:IRENE
Other - Last Name:HIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:1224 CORA ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2265
Mailing Address - Country:US
Mailing Address - Phone:253-228-4962
Mailing Address - Fax:
Practice Address - Street 1:7516 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8448
Practice Address - Country:US
Practice Address - Phone:253-228-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020793225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist