Provider Demographics
NPI:1255876306
Name:LETHERMAN, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:LETHERMAN
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 1:16191 NE 83RD ST UNIT C518
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-4057
Mailing Address - Country:US
Mailing Address - Phone:907-841-1492
Mailing Address - Fax:
Practice Address - Street 1:1299 156TH AVE NE STE 123
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-7562
Practice Address - Country:US
Practice Address - Phone:425-614-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60725106OtherMASSAGE THERAPIST LICENSE