=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982840872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LETICIA ALCALA LMT, NCBTMB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2008
-----------------------------------------------------
Last Update Date | 12/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5455 HWY 95
-----------------------------------------------------
City | FORT MOHAVE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-234-2087
-----------------------------------------------------
Fax | 928-763-6003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5455 HWY 95
-----------------------------------------------------
City | FORT MOHAVE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426-9227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-234-2087
-----------------------------------------------------
Fax | 928-763-6003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT-11064
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------