Provider Demographics
NPI:1669195111
Name:OLGUIN, ALEXANDRA ROSE (LMT, MMP)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ROSE
Last Name:OLGUIN
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SCOTLAND RD APT D5
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-4624
Mailing Address - Country:US
Mailing Address - Phone:719-369-5129
Mailing Address - Fax:
Practice Address - Street 1:3911 OUTLOOK BLVD STE B
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1624
Practice Address - Country:US
Practice Address - Phone:719-369-5129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0022299225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist