Provider Demographics
NPI:1710337183
Name:LEWIS, DANIELLE JO (MA, ATC, OTC)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:JO
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA, ATC, OTC
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 6042
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-6042
Mailing Address - Country:US
Mailing Address - Phone:970-343-9459
Mailing Address - Fax:
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:SUITE 400
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-479-5828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00009492255A2300X
CO13-1129246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant