Provider Demographics
NPI:1780160002
Name:LEGOLVAN, JOE HENRY (CMT)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:HENRY
Last Name:LEGOLVAN
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9691 W COCO CIR UNIT 203
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80128-9272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5912 S CODY ST STE 111
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-9541
Practice Address - Country:US
Practice Address - Phone:720-220-1687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0008220225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20161265269OtherCERTIFICATE OF GOOD STANDING