Provider Demographics
NPI:1023020278
Name:STUPANSKY, KATHLEEN MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:STUPANSKY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6979 S HOLLY CIR
Mailing Address - Street 2:STE 105
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-1577
Mailing Address - Country:US
Mailing Address - Phone:303-694-2295
Mailing Address - Fax:303-694-1843
Practice Address - Street 1:1551 PROFESSIONAL LN
Practice Address - Street 2:#145
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6972
Practice Address - Country:US
Practice Address - Phone:720-494-3290
Practice Address - Fax:720-494-3294
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06-6600Medicare Oscar/Certification