Basic Information
| Provider Information | |||||||||
| NPI: | 1700074499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | LEILANI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ESTEBAN | ||||||||
| OtherFirstName: | LEILANI | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 11009 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985081009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603522037 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1175 CENTER DR | ||||||||
| Address2: | 160 | ||||||||
| City: | DUPONT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983277733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539641559 | ||||||||
| FaxNumber: | 2539648495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 01/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00024496 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 225310 | 01 | WA | L&I | OTHER |