Provider Demographics
NPI:1770898728
Name:COMSTOCK, EILEEN MAE
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:MAE
Last Name:COMSTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:M
Other - Last Name:COMSTOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:13524 BETHEL BURLEY RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-7835
Mailing Address - Country:US
Mailing Address - Phone:253-857-6251
Mailing Address - Fax:
Practice Address - Street 1:13524 BETHEL BURLEY RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-7835
Practice Address - Country:US
Practice Address - Phone:253-857-6251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-15
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60066828225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0248282OtherWA STATE DEPT OF LABOR AND INDUSTRIES