Provider Demographics
NPI:1598091498
Name:IVERSEN, INGRID LYN (RPT)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:LYN
Last Name:IVERSEN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 E 2ND AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5498
Mailing Address - Country:US
Mailing Address - Phone:970-385-1773
Mailing Address - Fax:
Practice Address - Street 1:755 E 2ND AVE
Practice Address - Street 2:SUITE E
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5498
Practice Address - Country:US
Practice Address - Phone:970-385-1773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO4074225100000X
NMNM3725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM3725OtherNM LICENSE
COCO4074OtherLICENSE