Provider Demographics
NPI:1558610709
Name:WHITEHALL, CLARISSA DYANN (LMP)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:DYANN
Last Name:WHITEHALL
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 1:610 N MISSION ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2065
Mailing Address - Country:US
Mailing Address - Phone:509-662-4711
Mailing Address - Fax:
Practice Address - Street 1:610 N. MISSION ST
Practice Address - Street 2:STE 102
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1978
Practice Address - Country:US
Practice Address - Phone:509-662-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60304173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist