Healthcare Provider Details

I. General information

NPI: 1356799431
Provider Name (Legal Business Name): THERAPEUTIC MASSAGE FROM TETYANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2016
Last Update Date: 05/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12919 STROH RANCH CT UNIT B
PARKER CO
80134-7707
US

IV. Provider business mailing address

19630 CLUBHOUSE DR APT 232
PARKER CO
80138-6201
US

V. Phone/Fax

Practice location:
  • Phone: 720-366-1661
  • Fax:
Mailing address:
  • Phone: 720-366-1661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberMT.0014452
License Number StateCO

VIII. Authorized Official

Name: TETYANA GNATYUK
Title or Position: MASSAGE THERAPIST
Credential:
Phone: 720-366-1661