Provider Demographics
NPI:1629597182
Name:LESSEM, TOBI
Entity Type:Individual
Prefix:
First Name:TOBI
Middle Name:
Last Name:LESSEM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TOBI
Other - Middle Name:KITYANA
Other - Last Name:LESSEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMT, NMT
Mailing Address - Street 1:920 SHERMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945
Mailing Address - Country:US
Mailing Address - Phone:707-625-4163
Mailing Address - Fax:
Practice Address - Street 1:920 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3244
Practice Address - Country:US
Practice Address - Phone:707-625-4163
Practice Address - Fax:707-625-4163
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81-2940585OtherCITY
81-2940585OtherCITY OF SAN RAFAEL