Provider Demographics
NPI:1700878402
Name:AULT, KENNETH B (LMP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:B
Last Name:AULT
Suffix:
Gender:M
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:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:8910 184TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8531
Practice Address - Country:US
Practice Address - Phone:253-863-7510
Practice Address - Fax:253-863-5970
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010271225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8929366OtherCRIME VICTIMS
WA5632AUOtherREGENCE BS
WA146261OtherDEPT OF L&I