Provider Demographics
NPI:1538680749
Name:PETZL, MOLLY ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNE
Last Name:PETZL
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 1:2580 INTEGRITY CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1351
Mailing Address - Country:US
Mailing Address - Phone:719-659-9541
Mailing Address - Fax:
Practice Address - Street 1:2580 INTEGRITY CT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1351
Practice Address - Country:US
Practice Address - Phone:719-659-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0017199225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist