Provider Demographics
NPI:1952640096
Name:THEALL, WENDY L (CMT, BA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:THEALL
Suffix:
Gender:F
Credentials:CMT, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 ARNETT ST
Mailing Address - Street 2:#4
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST
Practice Address - Street 2:STE 215
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1088
Practice Address - Country:US
Practice Address - Phone:303-444-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-09
Last Update Date:2013-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT 0014474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist