Provider Demographics
NPI:1831820778
Name:TUCKER, SELAH M (LMT)
Entity type:Individual
Prefix:
First Name:SELAH
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 HARNEY ST APT 6
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2069
Mailing Address - Country:US
Mailing Address - Phone:971-203-4147
Mailing Address - Fax:
Practice Address - Street 1:1508 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3434
Practice Address - Country:US
Practice Address - Phone:360-820-3667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61274452225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist