Provider Demographics
NPI:1457177420
Name:SHATTUCK, GWENDOLYN KATHLEEN (LMT)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:KATHLEEN
Last Name:SHATTUCK
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 1:19519 38TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-2609
Mailing Address - Country:US
Mailing Address - Phone:206-235-6694
Mailing Address - Fax:
Practice Address - Street 1:19519 38TH AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-2609
Practice Address - Country:US
Practice Address - Phone:206-235-6694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61583202225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist