Provider Demographics
NPI:1538235130
Name:BOTHUM, MICHAEL GREGORY (MASSAGE THERAPIST LM)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:BOTHUM
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:2911 W NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-2378
Mailing Address - Country:US
Mailing Address - Phone:509-326-6669
Mailing Address - Fax:509-326-6669
Practice Address - Street 1:2911 W NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2378
Practice Address - Country:US
Practice Address - Phone:509-326-6669
Practice Address - Fax:509-326-6669
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist