Provider Demographics
NPI:1124539267
Name:LAURENCE, BEAU P (LMT)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:P
Last Name:LAURENCE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-2403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11275 E MISSISSIPPI AVE STE 1E8
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-2818
Practice Address - Country:US
Practice Address - Phone:303-363-9095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0015240225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist