Provider Demographics
NPI:1679729040
Name:ANDERSON, SHELLY RUTH (LMP)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:RUTH
Last Name:ANDERSON
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 1:2710 WILDERNESS DR SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4331
Mailing Address - Country:US
Mailing Address - Phone:360-402-5133
Mailing Address - Fax:
Practice Address - Street 1:2710 WILDERNESS DR SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-4331
Practice Address - Country:US
Practice Address - Phone:360-402-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-17
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024296225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist