Provider Demographics
NPI:1710721501
Name:BARNES, DEMETRI OMAR (LMT)
Entity type:Individual
Prefix:
First Name:DEMETRI
Middle Name:OMAR
Last Name:BARNES
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 1:901 S DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7517
Mailing Address - Country:US
Mailing Address - Phone:602-350-9956
Mailing Address - Fax:
Practice Address - Street 1:287 E FRYE RD STE 1D
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-6306
Practice Address - Country:US
Practice Address - Phone:480-300-1945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT20219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist