Provider Demographics
NPI:1205373602
Name:FAUSSETT, MARY (MOTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FAUSSETT
Suffix:
Gender:F
Credentials:MOTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 JUNIPER WAY
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-7966
Mailing Address - Country:US
Mailing Address - Phone:720-273-7532
Mailing Address - Fax:
Practice Address - Street 1:8401 ARISTA PL
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-4154
Practice Address - Country:US
Practice Address - Phone:720-777-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0001533261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation