Provider Demographics
NPI:1407192768
Name:KRUYSHOOP, KELLY (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KRUYSHOOP
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 1:2601 S LEMAY AVE
Mailing Address - Street 2:SUITE 35
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2295
Mailing Address - Country:US
Mailing Address - Phone:970-682-2083
Mailing Address - Fax:970-682-2592
Practice Address - Street 1:2601 S LEMAY AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2295
Practice Address - Country:US
Practice Address - Phone:970-682-2083
Practice Address - Fax:970-682-2592
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8437225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist