Provider Demographics
NPI:1356925119
Name:WEINBERG, MATTHEW ALAN (LMT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALAN
Last Name:WEINBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30412 227TH PL SE
Mailing Address - Street 2:
Mailing Address - City:BLACK DIAMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98010-1288
Mailing Address - Country:US
Mailing Address - Phone:707-710-6811
Mailing Address - Fax:
Practice Address - Street 1:27115 185TH AVE SE STE 107
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-8449
Practice Address - Country:US
Practice Address - Phone:707-710-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61108938225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANAMedicaid