Provider Demographics
NPI:1730807348
Name:DURHAM, MARISSA (LMT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DURHAM
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 1:1900 KEN PRATT BLVD APT 2212
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6993
Mailing Address - Country:US
Mailing Address - Phone:714-905-6159
Mailing Address - Fax:
Practice Address - Street 1:1900 KEN PRATT BLVD APT 2212
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6993
Practice Address - Country:US
Practice Address - Phone:714-905-6159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0024897225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist