Provider Demographics
NPI:1619427341
Name:MASCOTTI, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MASCOTTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19628 2ND PL W
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-7085
Mailing Address - Country:US
Mailing Address - Phone:206-856-5576
Mailing Address - Fax:
Practice Address - Street 1:297 CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2516
Practice Address - Country:US
Practice Address - Phone:206-856-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60089771225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60089771OtherMASSAGE THERAPIST