Provider Demographics
NPI:1225430606
Name:VAN BAVEL, CONNOR (MSCPT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:VAN BAVEL
Suffix:
Gender:M
Credentials:MSCPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13606 XAVIER LN
Mailing Address - Street 2:UNIT C
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-3604
Mailing Address - Country:US
Mailing Address - Phone:303-404-9494
Mailing Address - Fax:303-404-2252
Practice Address - Street 1:12297 PENNSYLVANIA ST
Practice Address - Street 2:SUITE 3
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-3165
Practice Address - Country:US
Practice Address - Phone:303-252-9400
Practice Address - Fax:303-255-9555
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2017-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000144743Medicaid
CO376382YNRPMedicare PIN