Provider Demographics
NPI:1629300389
Name:EBERWEIN, ANGELIQUE CECIEL (MT, CNMT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:CECIEL
Last Name:EBERWEIN
Suffix:
Gender:F
Credentials:MT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E YAMPA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2939
Mailing Address - Country:US
Mailing Address - Phone:719-322-6778
Mailing Address - Fax:719-344-2295
Practice Address - Street 1:7075 CAMPUS DR
Practice Address - Street 2:SUITE #210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-6523
Practice Address - Country:US
Practice Address - Phone:719-322-6778
Practice Address - Fax:719-344-2295
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3041225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist