Provider Demographics
NPI:1679946891
Name:SAMS, DEBRA (LMP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:SAMS
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 1:755 VANDERCOOK WAY STE 101A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4050
Mailing Address - Country:US
Mailing Address - Phone:360-577-0294
Mailing Address - Fax:360-577-2635
Practice Address - Street 1:755 VANDERCOOK WAY STE 101A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4050
Practice Address - Country:US
Practice Address - Phone:360-577-0294
Practice Address - Fax:360-577-2635
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60574639225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist