Provider Demographics
NPI:1538714860
Name:GRANATA, ALEX (LMT)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:GRANATA
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 1:1639 GAYLORD AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2654
Mailing Address - Country:US
Mailing Address - Phone:719-242-6170
Mailing Address - Fax:
Practice Address - Street 1:3920 N UNION BLVD STE 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4907
Practice Address - Country:US
Practice Address - Phone:719-471-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0022732225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist