Provider Demographics
NPI:1912378613
Name:GOLUB, YELENA A (MA60597652)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:A
Last Name:GOLUB
Suffix:
Gender:F
Credentials:MA60597652
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24612 104TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-4965
Mailing Address - Country:US
Mailing Address - Phone:253-520-2529
Mailing Address - Fax:
Practice Address - Street 1:24612 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-4965
Practice Address - Country:US
Practice Address - Phone:253-520-2529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60597652225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist