Provider Demographics
NPI:1679817217
Name:REALM
Entity Type:Organization
Organization Name:REALM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:K
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:RYT, RMT
Authorized Official - Phone:303-953-9892
Mailing Address - Street 1:1500 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1002
Mailing Address - Country:US
Mailing Address - Phone:303-953-9892
Mailing Address - Fax:
Practice Address - Street 1:1500 28TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1002
Practice Address - Country:US
Practice Address - Phone:303-953-9892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7891225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty