Provider Demographics
NPI:1265496194
Name:DETWILER, KIMBERLY R (MS, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:DETWILER
Suffix:
Gender:F
Credentials:MS, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 OPAL ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7059
Mailing Address - Country:US
Mailing Address - Phone:512-230-6171
Mailing Address - Fax:
Practice Address - Street 1:2150 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-7059
Practice Address - Country:US
Practice Address - Phone:512-230-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00017542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer