Provider Demographics
NPI:1407411341
Name:CRAIG, CARLEE (LMT)
Entity Type:Individual
Prefix:
First Name:CARLEE
Middle Name:
Last Name:CRAIG
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 1:2 PRINCE VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2140
Mailing Address - Country:US
Mailing Address - Phone:719-251-6855
Mailing Address - Fax:
Practice Address - Street 1:111 W EVANS AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-4215
Practice Address - Country:US
Practice Address - Phone:719-542-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0020482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COO658061Medicaid