Provider Demographics
NPI:1255641106
Name:AGENA, PHOEBE T A (LMP)
Entity type:Individual
Prefix:
First Name:PHOEBE
Middle Name:T A
Last Name:AGENA
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 1:3805 S. EDMUNDS ST.
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118
Mailing Address - Country:US
Mailing Address - Phone:206-755-4938
Mailing Address - Fax:
Practice Address - Street 1:3805 S. EDMUNDS ST.
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118
Practice Address - Country:US
Practice Address - Phone:206-755-4938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60101610225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist