Healthcare Provider Details

I. General information

NPI: 1295065167
Provider Name (Legal Business Name): KATHRYN DIANA WEISS RMT NCTMB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2439 BROADWAY STREET
BOULDER CO
80304
US

IV. Provider business mailing address

PO BOX 1369
BOULDER CO
80306-1369
US

V. Phone/Fax

Practice location:
  • Phone: 303-359-9278
  • Fax:
Mailing address:
  • Phone: 303-359-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9570
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: