Provider Demographics
NPI:1336842673
Name:EDEISTEIN, LUCY GRACE (LMT)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:GRACE
Last Name:EDEISTEIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 INTELCO LOOP SE BLDG 3
Mailing Address - Street 2:SUITE E
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6008
Mailing Address - Country:US
Mailing Address - Phone:360-972-2524
Mailing Address - Fax:360-972-2526
Practice Address - Street 1:4520 INTELCO LOOP SE BLDG 3
Practice Address - Street 2:SUITE E
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6008
Practice Address - Country:US
Practice Address - Phone:360-972-2524
Practice Address - Fax:360-972-2526
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61396526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist