Provider Demographics
NPI:1659865616
Name:SHOFNER, DOROTHY SUSAN (CERTIFIED MASSAGE TH)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:SUSAN
Last Name:SHOFNER
Suffix:
Gender:F
Credentials:CERTIFIED MASSAGE TH
Other - Prefix:MRS
Other - First Name:DOROTHY
Other - Middle Name:SUSAN
Other - Last Name:LESETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1235 E LINCOLN AVE APT 502
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1607 E LINCOLN AVE STE A
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1958
Practice Address - Country:US
Practice Address - Phone:714-921-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47130225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty