Provider Demographics
NPI:1922662493
Name:LEE, TERRALAR J (LMT)
Entity Type:Individual
Prefix:
First Name:TERRALAR
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
Credentials:LMT
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 926
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-0926
Mailing Address - Country:US
Mailing Address - Phone:360-642-3278
Mailing Address - Fax:
Practice Address - Street 1:113 OREGON AVE S
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3988
Practice Address - Country:US
Practice Address - Phone:360-642-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60730523225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist