Provider Demographics
NPI:1538613229
Name:BAILEY, AUSTIN (LMT)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 CAREY AVE
Mailing Address - Street 2:1C
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4423
Mailing Address - Country:US
Mailing Address - Phone:307-426-4321
Mailing Address - Fax:307-426-4320
Practice Address - Street 1:1651 CAREY AVE
Practice Address - Street 2:1C
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4423
Practice Address - Country:US
Practice Address - Phone:307-426-4321
Practice Address - Fax:307-426-4320
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYQL-17-35110225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist