Provider Demographics
NPI:1306382429
Name:WILKINS-BRANSON, LASEA (LMT)
Entity Type:Individual
Prefix:
First Name:LASEA
Middle Name:
Last Name:WILKINS-BRANSON
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 1:2615 SHOOTING STAR WAY
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-9244
Mailing Address - Country:US
Mailing Address - Phone:970-599-2395
Mailing Address - Fax:
Practice Address - Street 1:2615 SHOOTING STAR WAY
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-9244
Practice Address - Country:US
Practice Address - Phone:970-599-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0017698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist