Provider Demographics
NPI:1013739929
Name:BOUGHAL, EMILY DIANNE (LMT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:DIANNE
Last Name:BOUGHAL
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 1:2358 S HOSMER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3149
Mailing Address - Country:US
Mailing Address - Phone:253-468-4124
Mailing Address - Fax:
Practice Address - Street 1:3712 9TH ST SW STE A1
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3564
Practice Address - Country:US
Practice Address - Phone:253-880-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61508749225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist