Provider Demographics
NPI:1265978233
Name:WALLS, SHERRY (LMT, LMMT)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:LMT, LMMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6198 HIGHWAY 151
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137
Mailing Address - Country:US
Mailing Address - Phone:719-688-5099
Mailing Address - Fax:
Practice Address - Street 1:14324 US HWY 172 NORTH
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:719-688-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0006402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist