Provider Demographics
NPI:1205165149
Name:GURTISEN, CONSTANCE JEAN
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:JEAN
Last Name:GURTISEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 W CLEARWATER AVE
Mailing Address - Street 2:APT E9
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 JADWIN AVE
Practice Address - Street 2:SUITE E
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4255
Practice Address - Country:US
Practice Address - Phone:509-420-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60024922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist