Basic Information
| Provider Information | |||||||||
| NPI: | 1568400042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYRICK | ||||||||
| FirstName: | JOAN | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253300633 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 7728 204TH ST NE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982232500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604038250 | ||||||||
| FaxNumber: | 3604030917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7679705 | 01 | WA | AETNA | OTHER | 8854MY | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8875MY | 01 | WA | REGENCE BLUE SHIELD | OTHER | 0146797 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 8928862 | 01 | WA | L&I CRIME VICTIMS | OTHER |