Provider Demographics
NPI:1902130073
Name:COLBETH, TAMMY ANNE (CMT, LMT)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ANNE
Last Name:COLBETH
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 HWY 169 N.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2896
Mailing Address - Country:US
Mailing Address - Phone:763-557-9032
Mailing Address - Fax:763-557-9838
Practice Address - Street 1:4455 HWY 169 N.
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2896
Practice Address - Country:US
Practice Address - Phone:763-557-9032
Practice Address - Fax:763-557-9838
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN#MT3400143225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist