Provider Demographics
NPI:1164667622
Name:RUNDLE, TABETHA L (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TABETHA
Middle Name:L
Last Name:RUNDLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:CO
Mailing Address - Zip Code:80615-9062
Mailing Address - Country:US
Mailing Address - Phone:970-371-8892
Mailing Address - Fax:
Practice Address - Street 1:23830 COUNTY ROAD 48
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:CO
Practice Address - Zip Code:80645-8612
Practice Address - Country:US
Practice Address - Phone:970-451-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTA.0012605OtherPTA LICENSE