Provider Demographics
NPI:1073751590
Name:KOLLER, DENISE ALEXANDRA (LMT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ALEXANDRA
Last Name:KOLLER
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 1:7940 N JORNADA RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7252
Mailing Address - Country:US
Mailing Address - Phone:575-636-3479
Mailing Address - Fax:
Practice Address - Street 1:7940 N JORNADA RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7252
Practice Address - Country:US
Practice Address - Phone:575-636-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4650225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist