Provider Demographics
NPI:1730572256
Name:MACKIE, MELISSA MARIE (LMP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:MACKIE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:DUPLESIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 166
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-0166
Mailing Address - Country:US
Mailing Address - Phone:360-340-5166
Mailing Address - Fax:
Practice Address - Street 1:1061 SE STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-9195
Practice Address - Country:US
Practice Address - Phone:360-427-7461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60497798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist