Provider Demographics
NPI:1164644795
Name:MOUNTAIN DESERT THERAPY, PC.
Entity Type:Organization
Organization Name:MOUNTAIN DESERT THERAPY, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DUGUID
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-345-4515
Mailing Address - Street 1:PO BOX 350592
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80035
Mailing Address - Country:US
Mailing Address - Phone:303-345-4515
Mailing Address - Fax:
Practice Address - Street 1:11450 MELODY DRIVE
Practice Address - Street 2:C-101
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234
Practice Address - Country:US
Practice Address - Phone:303-345-4515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02204827Medicaid