Provider Demographics
NPI:1275017873
Name:CRAWFORD, OLIVER GAHLEN JR (PHD, LMT, MMP, CNMT)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:GAHLEN
Last Name:CRAWFORD
Suffix:JR
Gender:M
Credentials:PHD, LMT, MMP, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 N NORWOOD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-5668
Mailing Address - Country:US
Mailing Address - Phone:719-281-3473
Mailing Address - Fax:
Practice Address - Street 1:2025 N NORWOOD AVE STE B
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-5668
Practice Address - Country:US
Practice Address - Phone:719-281-3473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0020848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist