Provider Demographics
NPI:1962706630
Name:CROSS, MARY ALYCE (CMT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALYCE
Last Name:CROSS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PINE CONE DR
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-9201
Mailing Address - Country:US
Mailing Address - Phone:970-769-5776
Mailing Address - Fax:
Practice Address - Street 1:14324 US HIGHWAY 172N
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:970-563-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6304225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist