Provider Demographics
NPI:1033662739
Name:GRESL, AMANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GRESL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S AIRPORT RD
Mailing Address - Street 2:BLDG B, SUITE C
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6424
Mailing Address - Country:US
Mailing Address - Phone:720-491-3402
Mailing Address - Fax:
Practice Address - Street 1:600 S AIRPORT RD
Practice Address - Street 2:BLDG B, SUITE C
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6424
Practice Address - Country:US
Practice Address - Phone:720-491-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0014236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist