Provider Demographics
NPI:1871635003
Name:MIDDERHOFF, DEDERA A (LMP)
Entity type:Individual
Prefix:
First Name:DEDERA
Middle Name:A
Last Name:MIDDERHOFF
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 109TH AVE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374
Mailing Address - Country:US
Mailing Address - Phone:253-273-2792
Mailing Address - Fax:
Practice Address - Street 1:4111 S. MERIDIAN
Practice Address - Street 2:SUITE F
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374
Practice Address - Country:US
Practice Address - Phone:253-273-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020763225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist