Provider Demographics
NPI:1881116754
Name:FLYNN, DONALD (MT)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:FLYNN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 THUNDER MOUNTAIN DR UNIT 412
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-4856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:514 28 1/4 RD UNIT 4
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-4961
Practice Address - Country:US
Practice Address - Phone:970-644-5255
Practice Address - Fax:970-644-5255
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016901225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT.0016901OtherMASSAGE THERAPY LICENSE