Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT.0016804 | CO |
NPI | 1003289158 |
---|---|
Provider Name | Mr. Brent Haney |
First Address | Colorado Springs, CO 80909-1863 |
Second Address | Colorado Springs, CO 80909-1863 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2015 |
Last Update Date | 16/11/2021 |