Provider Demographics
NPI:1851913388
Name:BRADY, MELISA (LMT, RYT)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:LMT, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1662
Mailing Address - Street 2:
Mailing Address - City:PAONIA
Mailing Address - State:CO
Mailing Address - Zip Code:81428-1662
Mailing Address - Country:US
Mailing Address - Phone:801-879-5078
Mailing Address - Fax:
Practice Address - Street 1:211 GRAND AVE # 116
Practice Address - Street 2:
Practice Address - City:PAONIA
Practice Address - State:CO
Practice Address - Zip Code:81428-5092
Practice Address - Country:US
Practice Address - Phone:801-879-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0022063225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist