Provider Demographics
NPI:1336241090
Name:WIEDRICH, MONIQUE T (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:T
Last Name:WIEDRICH
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 1:2001 36TH LN NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-2559
Mailing Address - Country:US
Mailing Address - Phone:360-705-9692
Mailing Address - Fax:
Practice Address - Street 1:3948 CLEVELAND AVE SE STE A
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4023
Practice Address - Country:US
Practice Address - Phone:360-570-9580
Practice Address - Fax:360-570-9583
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017965225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0200946OtherDEPT. OF L&I