Healthcare Provider Details

I. General information

NPI: 1902451925
Provider Name (Legal Business Name): LETICIA DESIMONE MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 2ND ST
ENCINITAS CA
92024-4410
US

IV. Provider business mailing address

789 SAXONY RD UNIT A
ENCINITAS CA
92024-2352
US

V. Phone/Fax

Practice location:
  • Phone: 760-633-1970
  • Fax:
Mailing address:
  • Phone: 203-456-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number75642
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: