Provider Demographics
NPI:1598268567
Name:WILSON, PATTY RAELENE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:RAELENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 OLETTA LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-1648
Mailing Address - Country:US
Mailing Address - Phone:719-671-4317
Mailing Address - Fax:
Practice Address - Street 1:301 N MAIN ST STE 301
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3259
Practice Address - Country:US
Practice Address - Phone:719-671-4317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0013933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist