Provider Demographics
NPI:1063967826
Name:BRACHO, MARISELA (LMT)
Entity type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:BRACHO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790885
Mailing Address - Street 2:
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-0885
Mailing Address - Country:US
Mailing Address - Phone:808-283-7927
Mailing Address - Fax:
Practice Address - Street 1:1111 KAUPAKALUA RD
Practice Address - Street 2:
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-5239
Practice Address - Country:US
Practice Address - Phone:808-283-7927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-6080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist