Provider Demographics
NPI:1871998898
Name:DESMET, NICOLAS (LMT)
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:DESMET
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 1:3400 TABLE MESA DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5869
Mailing Address - Country:US
Mailing Address - Phone:303-499-9892
Mailing Address - Fax:
Practice Address - Street 1:3400 TABLE MESA DR
Practice Address - Street 2:SUITE 203
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5869
Practice Address - Country:US
Practice Address - Phone:303-499-9892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT12154225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist