Provider Demographics
NPI:1265795777
Name:ABBOTT, INGRID PALM (LMP)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:PALM
Last Name:ABBOTT
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 1:1804 33RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-2834
Mailing Address - Country:US
Mailing Address - Phone:360-918-4628
Mailing Address - Fax:360-705-3248
Practice Address - Street 1:541 MCPHEE RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5015
Practice Address - Country:US
Practice Address - Phone:360-867-0725
Practice Address - Fax:360-705-3248
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60290880225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist