Healthcare Provider Details

I. General information

NPI: 1336591809
Provider Name (Legal Business Name): ELISABETH ELLENBERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 TABLE MESA DR SUITE B
BOULDER CO
80305-4503
US

IV. Provider business mailing address

4710 TABLE MESA DR SUITE B
BOULDER CO
80305-4503
US

V. Phone/Fax

Practice location:
  • Phone: 303-499-9892
  • Fax:
Mailing address:
  • Phone: 303-499-9892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0017087
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: