Provider Demographics
NPI:1386246791
Name:TERRY, JOSEPHINE D
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:D
Last Name:TERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37351 COUNTY ROAD 26.6
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-9708
Mailing Address - Country:US
Mailing Address - Phone:719-680-3480
Mailing Address - Fax:
Practice Address - Street 1:257 N COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2610
Practice Address - Country:US
Practice Address - Phone:719-680-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0008578225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty