Provider Demographics
NPI:1609456094
Name:AVILA, SAMANTHA (MA60886820)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:MA60886820
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 NE 4TH ST APT J103
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-8819
Mailing Address - Country:US
Mailing Address - Phone:206-486-5554
Mailing Address - Fax:
Practice Address - Street 1:121 PELLY AVE N
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5714
Practice Address - Country:US
Practice Address - Phone:206-486-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60886820225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist