Provider Demographics
NPI:1891473286
Name:STAKELY, JOHNATHON BRANDON (MASSAGE THERAPY)
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:BRANDON
Last Name:STAKELY
Suffix:
Gender:M
Credentials:MASSAGE THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 S CIRCLE DR # 250I
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4113
Mailing Address - Country:US
Mailing Address - Phone:719-428-7020
Mailing Address - Fax:
Practice Address - Street 1:2860 S CIRCLE DR # 250I
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4113
Practice Address - Country:US
Practice Address - Phone:719-428-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0024865225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist