Provider Demographics
NPI:1164031555
Name:MCDONALD, JUSTIN (LMT, HBS, CFSC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:LMT, HBS, CFSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 DELIVERANCE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1675
Mailing Address - Country:US
Mailing Address - Phone:815-540-1688
Mailing Address - Fax:
Practice Address - Street 1:4740 FLINTRIDGE DR STE 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4273
Practice Address - Country:US
Practice Address - Phone:719-917-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0022782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist