Provider Demographics
NPI:1467683748
Name:MEZA, MARISOL (LMP)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:MEZA
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 1:301 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-1358
Mailing Address - Country:US
Mailing Address - Phone:509-882-1331
Mailing Address - Fax:509-882-2850
Practice Address - Street 1:301 DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1358
Practice Address - Country:US
Practice Address - Phone:509-882-1331
Practice Address - Fax:509-882-2850
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60099718225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist