Provider Demographics
NPI:1588958656
Name:WAUTLET, BREEONA M (LMT)
Entity type:Individual
Prefix:MISS
First Name:BREEONA
Middle Name:M
Last Name:WAUTLET
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 1:1315 MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-2500
Mailing Address - Country:US
Mailing Address - Phone:720-629-0258
Mailing Address - Fax:
Practice Address - Street 1:1315 MARIPOSA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-2500
Practice Address - Country:US
Practice Address - Phone:720-629-0258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist