Provider Demographics
NPI:1750555801
Name:BORGSTROM, KATHLEEN G (LMP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:G
Last Name:BORGSTROM
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-1239
Mailing Address - Country:US
Mailing Address - Phone:253-862-8590
Mailing Address - Fax:
Practice Address - Street 1:21157 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8457
Practice Address - Country:US
Practice Address - Phone:253-862-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-19
Last Update Date:2008-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017503225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA167869OtherLABOR AND INDUSTRIES