Provider Demographics
NPI:1295279255
Name:DEITZ, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:DEITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:DEROUSSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3823 SHORE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-1228
Mailing Address - Country:US
Mailing Address - Phone:206-354-8382
Mailing Address - Fax:
Practice Address - Street 1:7104 265TH ST NW STE 130
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6250
Practice Address - Country:US
Practice Address - Phone:206-354-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60708337225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist