Provider Demographics
NPI:1598390312
Name:WATLEY, TAYLOR ANNE (MT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANNE
Last Name:WATLEY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:ANNE
Other - Last Name:OLIVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:131 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3415
Mailing Address - Country:US
Mailing Address - Phone:719-924-9398
Mailing Address - Fax:719-924-9593
Practice Address - Street 1:131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3415
Practice Address - Country:US
Practice Address - Phone:719-924-9398
Practice Address - Fax:719-924-9593
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0021640225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist