Provider Demographics
NPI:1891870358
Name:ANDERSON, MOLLY M (LMP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:ANDERSON
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 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:100 DENNIS ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6523
Practice Address - Country:US
Practice Address - Phone:360-704-3300
Practice Address - Fax:360-704-7676
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA178353OtherDEPT OF LABOR & INDUSTRY
WA3242TIOtherREGENCE BLUE SHIELD
WA8931530OtherCRIME VICTIMS