Healthcare Provider Details

I. General information

NPI: 1952513996
Provider Name (Legal Business Name): MARY ELLEN (NMN) LAKE LMT, CNMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W COLORADO AVE SUITE 101
COLORADO SPRINGS CO
80904-3882
US

IV. Provider business mailing address

656 GLEN EYRIE CIR
COLORADO SPRINGS CO
80904-2139
US

V. Phone/Fax

Practice location:
  • Phone: 719-660-1686
  • Fax:
Mailing address:
  • Phone: 719-578-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number709188
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: