Provider Demographics
NPI:1780110585
Name:DE'AK, SANDRA (LMT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DE'AK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 ACME RD
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-8202
Mailing Address - Country:US
Mailing Address - Phone:503-516-6535
Mailing Address - Fax:
Practice Address - Street 1:288 E JEWETT BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-3000
Practice Address - Country:US
Practice Address - Phone:503-516-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4821225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist