Provider Demographics
NPI:1871015321
Name:NEBEKER, MICHAEL (MA 60771411)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:NEBEKER
Suffix:
Gender:M
Credentials:MA 60771411
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 97TH DR SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-4730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2130 97TH DR SE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-4730
Practice Address - Country:US
Practice Address - Phone:425-359-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-16
Last Update Date:2017-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60771411225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist