Healthcare Provider Details

I. General information

NPI: 1639998982
Provider Name (Legal Business Name): JULIET WINIFRED KOSS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 4TH ST SW
ALBUQUERQUE NM
87102-4142
US

IV. Provider business mailing address

1017 4TH ST SW
ALBUQUERQUE NM
87102-4142
US

V. Phone/Fax

Practice location:
  • Phone: 505-585-1711
  • Fax:
Mailing address:
  • Phone: 505-585-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-2023-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: