Provider Demographics
NPI:1700074499
Name:MOCK, LEILANI (LMP)
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:
Last Name:MOCK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:LEILANI
Other - Middle Name:S
Other - Last Name:ESTEBAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:
Practice Address - Street 1:1175 CENTER DR
Practice Address - Street 2:160
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-7733
Practice Address - Country:US
Practice Address - Phone:253-964-1559
Practice Address - Fax:253-964-8495
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024496225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA225310OtherL&I