Provider Demographics
NPI:1457565327
Name:STILL WATERS THERAPEUTIC PLLC
Entity Type:Organization
Organization Name:STILL WATERS THERAPEUTIC PLLC
Other - Org Name:LIMITED LIABILITY COMPANY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE ANNE
Authorized Official - Middle Name:MATHE
Authorized Official - Last Name:SIVRET
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:206-235-1958
Mailing Address - Street 1:22000 MARINE VIEW DR SO SUITE 202
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198
Mailing Address - Country:US
Mailing Address - Phone:206-235-1958
Mailing Address - Fax:206-824-6205
Practice Address - Street 1:22000 MARINE VIEW DR SO SUITE 202
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198
Practice Address - Country:US
Practice Address - Phone:206-235-1958
Practice Address - Fax:206-235-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015674225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty