Provider Demographics
NPI:1871142380
Name:NORTHERN LIGHTS MASSAGE, PLLC
Entity type:Organization
Organization Name:NORTHERN LIGHTS MASSAGE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:OLESYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRYVORUCHKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-857-7482
Mailing Address - Street 1:1711 12TH AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 WARREN AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4027
Practice Address - Country:US
Practice Address - Phone:206-588-5079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty