Individual
MISTY LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
105 E 10TH AVE, POST FALLS, ID 83854-5125
(208) 425-6891
Mailing address
105 E 10TH AVE, POST FALLS, ID 83854-5125
(208) 425-6891
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
MA00019204
WA
225700000X
Massage Therapist
Primary
MAS-2923
ID
Other
Enumeration date
02/11/2017
Last updated
02/11/2017
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