Provider Demographics
NPI:1619587268
Name:TALLANT, JUSTIN EDWARD (LMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:EDWARD
Last Name:TALLANT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 TABOR ST APT 25
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-4731
Mailing Address - Country:US
Mailing Address - Phone:303-901-3671
Mailing Address - Fax:
Practice Address - Street 1:1901 KIPLING ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-2822
Practice Address - Country:US
Practice Address - Phone:720-999-8550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023462225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist