Provider Demographics
NPI:1972039436
Name:FAHEY, MYKLOS (LMT)
Entity Type:Individual
Prefix:
First Name:MYKLOS
Middle Name:
Last Name:FAHEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1135
Mailing Address - Country:US
Mailing Address - Phone:253-853-1900
Mailing Address - Fax:
Practice Address - Street 1:3610 GRANDVIEW ST
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1135
Practice Address - Country:US
Practice Address - Phone:253-853-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60704857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist