Provider Demographics
NPI:1811323801
Name:COULTER, SUNRISE MOONSHADOW (LMT, LMP)
Entity type:Individual
Prefix:MR
First Name:SUNRISE
Middle Name:MOONSHADOW
Last Name:COULTER
Suffix:
Gender:M
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-0853
Mailing Address - Country:US
Mailing Address - Phone:541-306-0565
Mailing Address - Fax:
Practice Address - Street 1:542 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3079
Practice Address - Country:US
Practice Address - Phone:360-683-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18466225700000X
WAMA60408973225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist