Provider Demographics
NPI:1780141010
Name:BLOSS, MOLLY L
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:L
Last Name:BLOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-1135
Mailing Address - Country:US
Mailing Address - Phone:425-879-9967
Mailing Address - Fax:
Practice Address - Street 1:10090 MAIN ST APT H
Practice Address - Street 2:
Practice Address - City:PESHASTIN
Practice Address - State:WA
Practice Address - Zip Code:98847-9770
Practice Address - Country:US
Practice Address - Phone:425-879-9967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60926537225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist