Healthcare Provider Details

I. General information

NPI: 1629986856
Provider Name (Legal Business Name): MAXIMO EMMANS MENDIZABAL MT-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 MADRONA BEACH RD NW
OLYMPIA WA
98502-8855
US

IV. Provider business mailing address

1845 MADRONA BEACH RD NW
OLYMPIA WA
98502-8855
US

V. Phone/Fax

Practice location:
  • Phone: 360-870-8570
  • Fax:
Mailing address:
  • Phone: 360-870-8570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number16399
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: