Provider Demographics
NPI:1255839882
Name:MAYER, ANNA O (MA, R-DMT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:O
Last Name:MAYER
Suffix:
Gender:F
Credentials:MA, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 WILLIAMS FORK TRL APT 103
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3407
Mailing Address - Country:US
Mailing Address - Phone:248-462-4484
Mailing Address - Fax:
Practice Address - Street 1:8774 YATES DR STE 305A
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-6971
Practice Address - Country:US
Practice Address - Phone:248-462-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R-DMT-2287225600000X
CONLC.0106321101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1B8LR50Medicaid