Provider Demographics
NPI:1568909711
Name:WENTZ, MARISA SEANA (LMT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:SEANA
Last Name:WENTZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:SEANA
Other - Last Name:MOROVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14511 MCAULEY RD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-9134
Mailing Address - Country:US
Mailing Address - Phone:360-580-4215
Mailing Address - Fax:
Practice Address - Street 1:307 S 12TH AVE STE 9
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3138
Practice Address - Country:US
Practice Address - Phone:360-580-4215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60315675172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0316475OtherLABOR & INDUSTRIES