Healthcare Provider Details

I. General information

NPI: 1992013171
Provider Name (Legal Business Name): ELIZABETH COCKRILL WARD CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 CODY LN
BASALT CO
81621-9106
US

IV. Provider business mailing address

PO BOX 4006
BASALT CO
81621-4006
US

V. Phone/Fax

Practice location:
  • Phone: 970-927-2532
  • Fax:
Mailing address:
  • Phone: 970-309-0976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT - 5540
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: