Provider Demographics
NPI:1730231549
Name:BLACK, DAWN M (LMP)
Entity type:Individual
Prefix:MS
First Name:DAWN
Middle Name:M
Last Name:BLACK
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:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-0333
Mailing Address - Country:US
Mailing Address - Phone:360-249-1151
Mailing Address - Fax:360-533-1608
Practice Address - Street 1:2555 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-3930
Practice Address - Country:US
Practice Address - Phone:360-533-2630
Practice Address - Fax:360-533-1608
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015576225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0196969OtherLABOR AND INDUSTRIES