Provider Demographics
NPI:1053785188
Name:WYATT, MANDY (LMT # 5693)
Entity type:Individual
Prefix:MS
First Name:MANDY
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:LMT # 5693
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200624
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220
Mailing Address - Country:US
Mailing Address - Phone:720-345-8008
Mailing Address - Fax:
Practice Address - Street 1:8906 W BOWLES AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-8606
Practice Address - Country:US
Practice Address - Phone:720-345-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0005693225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist