Provider Demographics
NPI:1780075051
Name:WIETH, LAURA L (LMP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:WIETH
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 1:102 5TH AVE
Mailing Address - Street 2:#3-104
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354
Mailing Address - Country:US
Mailing Address - Phone:253-250-7270
Mailing Address - Fax:
Practice Address - Street 1:102 5TH AVE
Practice Address - Street 2:#3-104
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354
Practice Address - Country:US
Practice Address - Phone:253-250-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60519616225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist