Provider Demographics
NPI:1578179354
Name:DEMAYO, SHANTI
Entity Type:Individual
Prefix:
First Name:SHANTI
Middle Name:
Last Name:DEMAYO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTI
Other - Middle Name:
Other - Last Name:WALIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5350 TOMAH DR STE 1300
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6983
Mailing Address - Country:US
Mailing Address - Phone:303-396-2310
Mailing Address - Fax:
Practice Address - Street 1:5350 TOMAH DR STE 1300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6983
Practice Address - Country:US
Practice Address - Phone:303-396-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COM.T.0023148225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist