Provider Demographics
NPI:1497056162
Name:DEHARTY, AUDREY ELISE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ELISE
Last Name:DEHARTY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S CORONA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2427
Mailing Address - Country:US
Mailing Address - Phone:402-305-8264
Mailing Address - Fax:
Practice Address - Street 1:1270 N FORD ST
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-1967
Practice Address - Country:US
Practice Address - Phone:303-271-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist