Provider Demographics
NPI:1811564537
Name:KOTOHDA, NORITAKE (MA60779709)
Entity Type:Individual
Prefix:
First Name:NORITAKE
Middle Name:
Last Name:KOTOHDA
Suffix:
Gender:M
Credentials:MA60779709
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WENATCHEE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2201
Mailing Address - Country:US
Mailing Address - Phone:509-670-0327
Mailing Address - Fax:
Practice Address - Street 1:25 N WENATCHEE AVE STE 110
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2201
Practice Address - Country:US
Practice Address - Phone:509-670-0327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60779709225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist