Provider Demographics
NPI:1952715013
Name:WILLIS, CASSIE (LMP)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:WILLIS
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 1:854 WRIGLEY LN SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-4600
Mailing Address - Country:US
Mailing Address - Phone:360-584-3466
Mailing Address - Fax:
Practice Address - Street 1:1105 IRVING ST SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6353
Practice Address - Country:US
Practice Address - Phone:360-584-3466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009315225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist