Provider Demographics
NPI:1821460841
Name:DENHAM, CORISSA
Entity Type:Individual
Prefix:
First Name:CORISSA
Middle Name:
Last Name:DENHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORISSA
Other - Middle Name:
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:667 GRANT RD STE 3
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-7818
Mailing Address - Country:US
Mailing Address - Phone:206-407-4978
Mailing Address - Fax:
Practice Address - Street 1:667 GRANT RD STE 3
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-7818
Practice Address - Country:US
Practice Address - Phone:206-407-4978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016998225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist