Provider Demographics
NPI:1679289789
Name:LAVENBURG, GREGORY (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LAVENBURG
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 PANORAMA
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6520
Mailing Address - Country:US
Mailing Address - Phone:302-547-5558
Mailing Address - Fax:
Practice Address - Street 1:128 W 14TH ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5100
Practice Address - Country:US
Practice Address - Phone:970-880-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0024302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist