Provider Demographics
NPI:1215002167
Name:DURHAM, CAROLYN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:DURHAM
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 1:611 N NEVADA AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1099
Mailing Address - Country:US
Mailing Address - Phone:719-229-9235
Mailing Address - Fax:719-447-9262
Practice Address - Street 1:611 N NEVADA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1099
Practice Address - Country:US
Practice Address - Phone:719-229-9235
Practice Address - Fax:719-447-9262
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO045617-00OtherNCTMB #
CO1335OtherSTATE OF COLORADO, DEPT OF REGULARTORY AGENCIES, DIVISION OF REGISTRATIONS