Provider Demographics
NPI:1912337213
Name:WALLACE, ERIN ELIZABETH (LMP)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:ELIZABETH
Last Name:WALLACE
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 1:115 30TH AVE
Mailing Address - Street 2:APT B
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-6229
Mailing Address - Country:US
Mailing Address - Phone:206-501-7742
Mailing Address - Fax:
Practice Address - Street 1:115 30TH AVE
Practice Address - Street 2:APT B
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-6229
Practice Address - Country:US
Practice Address - Phone:206-501-7742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60415302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist