Provider Demographics
NPI:1336928019
Name:GHORASHI, KELLEY D (LMT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:D
Last Name:GHORASHI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 CORNWALL CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5356
Mailing Address - Country:US
Mailing Address - Phone:719-440-2477
Mailing Address - Fax:
Practice Address - Street 1:7710 N UNION BLVD STE 100G
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4085
Practice Address - Country:US
Practice Address - Phone:719-440-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005467225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist