Provider Demographics
NPI:1760786784
Name:SOURS, SHALA DAWN (NCMT)
Entity Type:Individual
Prefix:
First Name:SHALA
Middle Name:DAWN
Last Name:SOURS
Suffix:
Gender:F
Credentials:NCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 N 12TH ST
Mailing Address - Street 2:5
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-3165
Mailing Address - Country:US
Mailing Address - Phone:970-623-1176
Mailing Address - Fax:
Practice Address - Street 1:514 28 1/4 RD
Practice Address - Street 2:1
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-4961
Practice Address - Country:US
Practice Address - Phone:970-242-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4319225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist