Provider Demographics
NPI:1720637457
Name:MASSEY, AUDRA
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:MASSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4423
Mailing Address - Country:US
Mailing Address - Phone:970-249-9683
Mailing Address - Fax:
Practice Address - Street 1:1043 RIDGE ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4423
Practice Address - Country:US
Practice Address - Phone:970-249-9683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
COPTL.0016306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist