Provider Demographics
NPI:1467400754
Name:PACKARD, CAROLYN ANN (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:PACKARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3831
Mailing Address - Country:US
Mailing Address - Phone:970-765-0818
Mailing Address - Fax:970-497-8410
Practice Address - Street 1:310 S 9TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:970-240-4015
Practice Address - Fax:970-249-1983
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA102748Medicare PIN
CO805405Medicare PIN
COS68495Medicare UPIN