Provider Demographics
NPI:1013692276
Name:CERVANTES, MINDY DAWN (LMT)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:DAWN
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:MINDY
Other - Middle Name:DAWN
Other - Last Name:CERVANTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MINDY STAUB, LMT
Mailing Address - Street 1:4846 HIRAM AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-3018
Mailing Address - Country:US
Mailing Address - Phone:435-580-9461
Mailing Address - Fax:
Practice Address - Street 1:4846 HIRAM AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-3018
Practice Address - Country:US
Practice Address - Phone:435-580-9461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3001225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty