Provider Demographics
NPI:1912699281
Name:AVALOS, GINA REALME (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:REALME
Last Name:AVALOS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 ROCKY AVE NE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:WA
Mailing Address - Zip Code:98848-9380
Mailing Address - Country:US
Mailing Address - Phone:509-398-3765
Mailing Address - Fax:
Practice Address - Street 1:311 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98848-1227
Practice Address - Country:US
Practice Address - Phone:509-398-3765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMASS.MA.61407276225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist