Provider Demographics
NPI:1841609856
Name:CRETTOL, DAVID LEROY (LMT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LEROY
Last Name:CRETTOL
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 1:212 W IRONWOOD DR STE D
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1403
Mailing Address - Country:US
Mailing Address - Phone:208-659-6459
Mailing Address - Fax:
Practice Address - Street 1:2005 N IRONWOOD PKWY STE 216
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2647
Practice Address - Country:US
Practice Address - Phone:208-659-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7258225700000X
IDMAS-3256225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist