Provider Demographics
NPI:1033234752
Name:BREIDENBACH, ROBERTA M (PT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:M
Last Name:BREIDENBACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:M
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:1625 MEDICAL CENTER PT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8731
Mailing Address - Country:US
Mailing Address - Phone:719-494-1409
Mailing Address - Fax:
Practice Address - Street 1:1625 MEDICAL CENTER PT
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-8731
Practice Address - Country:US
Practice Address - Phone:719-474-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist