Provider Demographics
NPI:1891348330
Name:GIPSON, TIA EVANGELINE
Entity Type:Individual
Prefix:MRS
First Name:TIA
Middle Name:EVANGELINE
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TIA
Other - Middle Name:EVEANGELINE
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3320 W MCGRAW ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-3241
Mailing Address - Country:US
Mailing Address - Phone:206-330-9741
Mailing Address - Fax:
Practice Address - Street 1:3320 W MCGRAW ST STE 4
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3241
Practice Address - Country:US
Practice Address - Phone:206-330-9741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60937659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist