Provider Demographics
NPI:1851044556
Name:IDE-MOTTA, ALISSA (LAC)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:IDE-MOTTA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CROSBY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4557
Mailing Address - Country:US
Mailing Address - Phone:626-429-6490
Mailing Address - Fax:
Practice Address - Street 1:28 WATER ST
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4080
Practice Address - Country:US
Practice Address - Phone:207-563-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty