Individual
GARY EDWARD BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMP
Contact information
Practice address
205 CLARK PL SE, TUMWATER, WA 98501-4062
(360) 570-0401
Mailing address
124 SILVERTHISTLE RD, WINLOCK, WA 98596-9731
(360) 304-9126
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
MA 60326924
WA
Other
Enumeration date
10/17/2014
Last updated
10/17/2014
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