Provider Demographics
NPI:1235649138
Name:COSSIO, KEEGAN SHEA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:SHEA
Last Name:COSSIO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:KEEGAN
Other - Middle Name:SHEA
Other - Last Name:WICKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:9000 E NICHOLS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3429
Mailing Address - Country:US
Mailing Address - Phone:406-396-7532
Mailing Address - Fax:
Practice Address - Street 1:3220 N RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1556
Practice Address - Country:US
Practice Address - Phone:406-396-7532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MTATR-LAT-LIC-18812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer