Provider Demographics
NPI:1508689852
Name:DENNIS, KELISHA MONIQUE
Entity type:Individual
Prefix:
First Name:KELISHA
Middle Name:MONIQUE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 W LA SALLE ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-3458
Mailing Address - Country:US
Mailing Address - Phone:100-000-0000
Mailing Address - Fax:
Practice Address - Street 1:2715 W LA SALLE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-3458
Practice Address - Country:US
Practice Address - Phone:510-696-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-29860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist