Provider Demographics
NPI:1013772037
Name:ANGELO, MICHAEL STEPHEN (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:ANGELO
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 1:4444 6TH AVE SE APT 342
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1086
Mailing Address - Country:US
Mailing Address - Phone:252-665-1669
Mailing Address - Fax:
Practice Address - Street 1:6002 MOUNT TACOMA DR SW STE B
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2703
Practice Address - Country:US
Practice Address - Phone:253-475-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61513169225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist