Provider Demographics
NPI:1194458984
Name:COLSTON, ELSA ANNE (LMT)
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:ANNE
Last Name:COLSTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 1/2 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-2308
Mailing Address - Country:US
Mailing Address - Phone:304-719-9321
Mailing Address - Fax:
Practice Address - Street 1:129 MAIN ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4615
Practice Address - Country:US
Practice Address - Phone:304-719-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2012-3069225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2012-3069OtherWV BOARD OF MASSAGE THERAPY