Provider Demographics
NPI:1932475399
Name:HEBERLE, POLLY J (LAC, LMP)
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:J
Last Name:HEBERLE
Suffix:
Gender:F
Credentials:LAC, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 S TULLOCH RD
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-7583
Mailing Address - Country:US
Mailing Address - Phone:360-348-2717
Mailing Address - Fax:
Practice Address - Street 1:328 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1812
Practice Address - Country:US
Practice Address - Phone:360-794-4500
Practice Address - Fax:360-863-1640
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014217225700000X
WAAC60208211171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist