Provider Demographics
NPI:1982960076
Name:DE SIMONE, MICHELINA (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELINA
Middle Name:
Last Name:DE SIMONE
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 1:326 134TH PL SW
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6823
Mailing Address - Country:US
Mailing Address - Phone:425-931-1657
Mailing Address - Fax:
Practice Address - Street 1:11419 19TH AVE SE STE A109
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5120
Practice Address - Country:US
Practice Address - Phone:425-379-2556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA 60168934225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist