Provider Demographics
NPI:1215522438
Name:YOUNG, ANNIE GRACE (LMT, LNMT, CCT)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:GRACE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LMT, LNMT, CCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 COOLWATER DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-5542
Mailing Address - Country:US
Mailing Address - Phone:719-922-5300
Mailing Address - Fax:
Practice Address - Street 1:4740 FLINTRIDGE DR STE 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4273
Practice Address - Country:US
Practice Address - Phone:719-917-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0023808225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty