Provider Demographics
NPI:1548499502
Name:MENDOZA, ALIS (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MS
First Name:ALIS
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1568
Mailing Address - Country:US
Mailing Address - Phone:509-855-6921
Mailing Address - Fax:509-488-0818
Practice Address - Street 1:116 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1304
Practice Address - Country:US
Practice Address - Phone:509-855-6921
Practice Address - Fax:509-488-0818
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023776225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist