Provider Demographics
NPI:1164818274
Name:MCCUISTION, DIRK (LMT)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:
Last Name:MCCUISTION
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 1:1640 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6219
Mailing Address - Country:US
Mailing Address - Phone:303-938-0388
Mailing Address - Fax:
Practice Address - Street 1:1640 BROADWAY
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-6219
Practice Address - Country:US
Practice Address - Phone:303-938-0388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0010742225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist