Provider Demographics
NPI:1689050049
Name:WIRTA, HANNAH TEAL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:TEAL
Last Name:WIRTA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:DODDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1760 E KEN PRATT BLVD STE 405
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5311
Mailing Address - Country:US
Mailing Address - Phone:720-718-5400
Mailing Address - Fax:720-718-5991
Practice Address - Street 1:1760 E KEN PRATT BLVD STE 405
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-5311
Practice Address - Country:US
Practice Address - Phone:720-718-5400
Practice Address - Fax:720-718-5991
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60559764225100000X
COPTL.0018748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0349709OtherWA L&I
WA1689050049Medicaid
WAG8944526Medicare PIN
WAG8944527Medicare PIN
WAG8944525Medicare PIN
WA1689050049Medicaid