Provider Demographics
NPI:1801397161
Name:FAVORITE, ALISHA ANNETTE
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:ANNETTE
Last Name:FAVORITE
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 1:303 POTRERO ST STE 42-103
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2779
Mailing Address - Country:US
Mailing Address - Phone:831-466-9307
Mailing Address - Fax:
Practice Address - Street 1:303 POTRERO ST STE 42-103
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2779
Practice Address - Country:US
Practice Address - Phone:831-466-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6292225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist