Provider Demographics
NPI:1518199603
Name:AVIDANE, JULIA BRETT (DPT)
Entity Type:Individual
Prefix:DR
First Name:JULIA
Middle Name:BRETT
Last Name:AVIDANE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4883
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631
Mailing Address - Country:US
Mailing Address - Phone:970-688-2211
Mailing Address - Fax:
Practice Address - Street 1:1140 EDWARDS VILLAGE BLVD
Practice Address - Street 2:B208
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-569-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 24831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1211937OtherPT
FL24831OtherPT
CAPT35960OtherLICENSE