Provider Demographics
NPI:1548692650
Name:LAUB, CRYSTAL R (LMP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:R
Last Name:LAUB
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 1:4800 JACKSON AVE SE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-1109
Mailing Address - Country:US
Mailing Address - Phone:360-876-4120
Mailing Address - Fax:360-895-0496
Practice Address - Street 1:4800 JACKSON AVE SE STE 104
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-1109
Practice Address - Country:US
Practice Address - Phone:360-876-4120
Practice Address - Fax:360-895-0496
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0219468OtherSTATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES
WA2007110961153637310OtherHEALTHWAYS WHOLEHEALTH NETWORKS