Provider Demographics
NPI:1902511801
Name:VILLOPOTO, DARLA KAY (LMT)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:KAY
Last Name:VILLOPOTO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 1/2 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2241
Mailing Address - Country:US
Mailing Address - Phone:208-790-7124
Mailing Address - Fax:
Practice Address - Street 1:3510 12TH ST STE 200
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5575
Practice Address - Country:US
Practice Address - Phone:208-799-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4791225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist