Provider Demographics
NPI:1447525860
Name:SHEA, MIRA (MSOM LMT)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:MSOM LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 KENYON ST NW STE 13
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4578
Mailing Address - Country:US
Mailing Address - Phone:360-688-4282
Mailing Address - Fax:
Practice Address - Street 1:222 KENYON ST NW STE 13
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4578
Practice Address - Country:US
Practice Address - Phone:360-688-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60231148225700000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist