Provider Demographics
NPI:1558515098
Name:DENNIS, JUSTIN T (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 YELLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5229
Mailing Address - Country:US
Mailing Address - Phone:307-444-4466
Mailing Address - Fax:307-444-4468
Practice Address - Street 1:96 YELLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5229
Practice Address - Country:US
Practice Address - Phone:307-444-4466
Practice Address - Fax:307-444-4468
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPT 11689225100000X
CA34971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF298ZMedicare PIN
COPENDINGMedicare PIN