Provider Demographics
NPI:1407931488
Name:COLETTA, DAVID LAWRENCE (MPT, CMPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:COLETTA
Suffix:
Gender:M
Credentials:MPT, CMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 W COLLEGE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4915
Mailing Address - Country:US
Mailing Address - Phone:406-556-0562
Mailing Address - Fax:406-556-0965
Practice Address - Street 1:1823 W COLLEGE ST STE 100
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4915
Practice Address - Country:US
Practice Address - Phone:406-556-0562
Practice Address - Fax:406-556-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1577PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0346358Medicaid
MT0346426Medicaid