Provider Demographics
NPI:1689905572
Name:GORESLINE, LAURA JEAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:GORESLINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4692 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6735
Mailing Address - Country:US
Mailing Address - Phone:303-494-6544
Mailing Address - Fax:
Practice Address - Street 1:2210 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1456
Practice Address - Country:US
Practice Address - Phone:303-651-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-17
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist