Provider Demographics
NPI:1255714226
Name:INTEGRATION THERAPY, LLC
Entity type:Organization
Organization Name:INTEGRATION THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:505-780-8783
Mailing Address - Street 1:1012 MARQUEZ PL
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1834
Mailing Address - Country:US
Mailing Address - Phone:505-780-8783
Mailing Address - Fax:505-780-8794
Practice Address - Street 1:TREASURY CENTER 10
Practice Address - Street 2:CRESTED BUTTE WAY STE L2
Practice Address - City:MT. CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81225-0154
Practice Address - Country:US
Practice Address - Phone:970-251-5462
Practice Address - Fax:970-251-5463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2509261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy