Provider Demographics
NPI:1023227709
Name:CARROLL-FRY, HEATHER MICHELLE (LMP)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MICHELLE
Last Name:CARROLL-FRY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 SW 338TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-3209
Mailing Address - Country:US
Mailing Address - Phone:253-815-0141
Mailing Address - Fax:
Practice Address - Street 1:28610 MAPLE VALLEY BLACK DIAMOND RD SE STE 120
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8199
Practice Address - Country:US
Practice Address - Phone:253-307-0046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist