Provider Demographics
NPI:1720289234
Name:SMALL, COLEEN ERIN (LMP)
Entity Type:Individual
Prefix:MS
First Name:COLEEN
Middle Name:ERIN
Last Name:SMALL
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:PO BOX 30068
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98113-2068
Mailing Address - Country:US
Mailing Address - Phone:206-609-7282
Mailing Address - Fax:
Practice Address - Street 1:8401 5TH AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4180
Practice Address - Country:US
Practice Address - Phone:206-609-7282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006402172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASM5142OtherREGENCE BLUE SHIELD WA
WA424-10OtherWA LABOR AND INDUSTRIES