Provider Demographics
NPI:1952695900
Name:ETTELSON, LEON (LMP)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:ETTELSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 S I ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-3638
Mailing Address - Country:US
Mailing Address - Phone:206-375-3021
Mailing Address - Fax:
Practice Address - Street 1:510 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-2312
Practice Address - Country:US
Practice Address - Phone:206-375-3021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60215066225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist