Provider Demographics
NPI:1710030770
Name:TREJO, CARISA ANN
Entity Type:Individual
Prefix:
First Name:CARISA
Middle Name:ANN
Last Name:TREJO
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 1:327 W 8TH AVE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2565
Mailing Address - Country:US
Mailing Address - Phone:509-624-0567
Mailing Address - Fax:
Practice Address - Street 1:327 W 8TH AVE
Practice Address - Street 2:SUITE 222
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2565
Practice Address - Country:US
Practice Address - Phone:509-624-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0128193OtherLABOR AND INDUSTRIES