Provider Demographics
NPI:1780929687
Name:CHAMBERLAIN, KATY (LMP, CCT)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:LMP, CCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-9496
Mailing Address - Country:US
Mailing Address - Phone:360-202-9720
Mailing Address - Fax:
Practice Address - Street 1:2118 RIVERSIDE DR STE 105
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-424-6104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60303226225700000X
MI7501010961225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist