Provider Demographics
NPI:1801082524
Name:EAGEN-POCH, MARY F (LMP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:EAGEN-POCH
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 1:260 NW GOLDEN HILLS DR SPC 14
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-9769
Mailing Address - Country:US
Mailing Address - Phone:509-592-0954
Mailing Address - Fax:
Practice Address - Street 1:1125 NE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-0001
Practice Address - Country:US
Practice Address - Phone:509-335-7492
Practice Address - Fax:509-335-2092
Is Sole Proprietor?:No
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist