Provider Demographics
NPI:1871753590
Name:KOVASH, SHALESA MARIE (LMP)
Entity type:Individual
Prefix:MISS
First Name:SHALESA
Middle Name:MARIE
Last Name:KOVASH
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 1:1219 COLE ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2636
Mailing Address - Country:US
Mailing Address - Phone:136-082-5437
Mailing Address - Fax:
Practice Address - Street 1:43804 284TH AVE SE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-9280
Practice Address - Country:US
Practice Address - Phone:253-736-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024313225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist