Provider Demographics
NPI:1649509373
Name:ROCHA, SHAWNTA SHANESE
Entity type:Individual
Prefix:
First Name:SHAWNTA
Middle Name:SHANESE
Last Name:ROCHA
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 1:11613 33RD CT NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-8741
Mailing Address - Country:US
Mailing Address - Phone:425-971-8398
Mailing Address - Fax:
Practice Address - Street 1:303 91ST AVE NE
Practice Address - Street 2:SUITE #A103
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-2541
Practice Address - Country:US
Practice Address - Phone:425-971-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60116964225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist