Provider Demographics
NPI:1043428873
Name:KOFFLER, BREANA LYNN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:BREANA
Middle Name:LYNN
Last Name:KOFFLER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10650 YATES DR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-1984
Mailing Address - Country:US
Mailing Address - Phone:303-912-4959
Mailing Address - Fax:
Practice Address - Street 1:413 SUMMIT BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-8294
Practice Address - Country:US
Practice Address - Phone:303-499-6565
Practice Address - Fax:303-499-8585
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7869225100000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7869OtherPT LISCENSE NUMBER
CO7869OtherPT LISCENSE NUMBER