Provider Demographics
NPI:1861209058
Name:MOTTER, AVA (CMP)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:
Last Name:MOTTER
Suffix:
Gender:F
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 BOULDER LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7417
Mailing Address - Country:US
Mailing Address - Phone:707-694-8913
Mailing Address - Fax:
Practice Address - Street 1:808 DONAHUE ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5434
Practice Address - Country:US
Practice Address - Phone:707-322-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54654225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist