Provider Demographics
NPI:1336721539
Name:SAMUELSEN, HOLLYANNE (MA, BCTMB)
Entity Type:Individual
Prefix:
First Name:HOLLYANNE
Middle Name:
Last Name:SAMUELSEN
Suffix:
Gender:F
Credentials:MA, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 GRIFFIN AVE # 914
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3418
Mailing Address - Country:US
Mailing Address - Phone:206-915-3617
Mailing Address - Fax:
Practice Address - Street 1:709 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3419
Practice Address - Country:US
Practice Address - Phone:253-350-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60002568225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist