Provider Demographics
NPI:1477152536
Name:MCFADDEN, MARISA BERNADETTE (LMT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:BERNADETTE
Last Name:MCFADDEN
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 1:13460 W WINCH AVE
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-7619
Mailing Address - Country:US
Mailing Address - Phone:208-964-4913
Mailing Address - Fax:
Practice Address - Street 1:1624 E SELTICE WAY
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7022
Practice Address - Country:US
Practice Address - Phone:208-777-0128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4182225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist