Provider Demographics
NPI:1942054333
Name:PRAG, TIMOTHY MOTOYUKI (LMT, DSOM)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MOTOYUKI
Last Name:PRAG
Suffix:
Gender:M
Credentials:LMT, DSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 RIVER VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LYLE
Mailing Address - State:WA
Mailing Address - Zip Code:98635-9618
Mailing Address - Country:US
Mailing Address - Phone:503-757-4478
Mailing Address - Fax:
Practice Address - Street 1:363 E JEWETT BLVD
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-3001
Practice Address - Country:US
Practice Address - Phone:503-243-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMASS.MA.61432321225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist