Provider Demographics
NPI:1700069473
Name:WALDENBERG, MORIAH HAMLIN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MORIAH
Middle Name:HAMLIN
Last Name:WALDENBERG
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 1:110 N BLAKELEY ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1823
Mailing Address - Country:US
Mailing Address - Phone:425-308-4812
Mailing Address - Fax:360-794-9377
Practice Address - Street 1:110 N BLAKELEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1823
Practice Address - Country:US
Practice Address - Phone:425-308-4812
Practice Address - Fax:360-794-9377
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist