Provider Demographics
NPI:1508349085
Name:BARRAZA, SELENA (MT0020077)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:BARRAZA
Suffix:
Gender:F
Credentials:MT0020077
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 FARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-2684
Mailing Address - Country:US
Mailing Address - Phone:719-287-3403
Mailing Address - Fax:
Practice Address - Street 1:411 LAKEWOOD CIR STE B102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2670
Practice Address - Country:US
Practice Address - Phone:719-593-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0020077225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$OtherSSN EIN