Provider Demographics
NPI:1316355910
Name:MACON, SUMMER (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SUMMER
Middle Name:
Last Name:MACON
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 1:360 COUNTY ROAD 122
Mailing Address - Street 2:
Mailing Address - City:HESPERUS
Mailing Address - State:CO
Mailing Address - Zip Code:81326-9447
Mailing Address - Country:US
Mailing Address - Phone:575-639-0778
Mailing Address - Fax:
Practice Address - Street 1:360 COUNTY ROAD 122
Practice Address - Street 2:
Practice Address - City:HESPERUS
Practice Address - State:CO
Practice Address - Zip Code:81326-9447
Practice Address - Country:US
Practice Address - Phone:575-639-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-27
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013409225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant