Provider Demographics
NPI:1538395207
Name:KNOLL, MISTI DAWN (LMT)
Entity type:Individual
Prefix:MRS
First Name:MISTI
Middle Name:DAWN
Last Name:KNOLL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:MISTI
Other - Middle Name:DAWN
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 COOKS HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9072
Mailing Address - Country:US
Mailing Address - Phone:360-736-2853
Mailing Address - Fax:360-736-4159
Practice Address - Street 1:1800 COOKS HILL RD STE A
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9072
Practice Address - Country:US
Practice Address - Phone:360-736-2853
Practice Address - Fax:360-736-4159
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022257225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist