Provider Demographics
NPI:1437779485
Name:DEICHMAN, RENEE C (LMT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:C
Last Name:DEICHMAN
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 1:9335 WOLF PACK TER
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7676
Mailing Address - Country:US
Mailing Address - Phone:719-330-5628
Mailing Address - Fax:
Practice Address - Street 1:3055 AUSTIN BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5748
Practice Address - Country:US
Practice Address - Phone:719-266-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0005992225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist