Provider Demographics
NPI:1497060610
Name:MENDIVE, KARISSA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:MARIE
Last Name:MENDIVE
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 1:2452 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-4617
Mailing Address - Country:US
Mailing Address - Phone:541-485-6915
Mailing Address - Fax:
Practice Address - Street 1:159 E 15TH AVE APT 2
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4083
Practice Address - Country:US
Practice Address - Phone:541-485-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10172225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist