Provider Demographics
NPI:1801545355
Name:SHANK, GRACY (MA60417755)
Entity type:Individual
Prefix:
First Name:GRACY
Middle Name:
Last Name:SHANK
Suffix:
Gender:F
Credentials:MA60417755
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CASCADE AVE UNIT 203
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:98252-8819
Mailing Address - Country:US
Mailing Address - Phone:206-788-6530
Mailing Address - Fax:
Practice Address - Street 1:106 CASCADE AVE UNIT 203
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-8819
Practice Address - Country:US
Practice Address - Phone:206-788-6530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60417755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist