Provider Demographics
NPI:1245784495
Name:VITORIA, NELLY
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:VITORIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NELLY
Other - Middle Name:
Other - Last Name:VITORIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1630 30TH ST
Mailing Address - Street 2:STE. A
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1044
Mailing Address - Country:US
Mailing Address - Phone:303-263-2661
Mailing Address - Fax:
Practice Address - Street 1:1690 30TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1034
Practice Address - Country:US
Practice Address - Phone:303-443-0496
Practice Address - Fax:303-447-2741
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0011699225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist