Provider Demographics
NPI:1669775649
Name:SUNDBERG, NAOMI IRENE (LMP)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:IRENE
Last Name:SUNDBERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6406
Mailing Address - Country:US
Mailing Address - Phone:360-738-0926
Mailing Address - Fax:
Practice Address - Street 1:420 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-738-0926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00020647225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist