Provider Demographics
NPI:1780690768
Name:WELCH, JUSTIN MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:WELCH
Suffix:
Gender:M
Credentials:PT, DPT
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 4869
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-4869
Mailing Address - Country:US
Mailing Address - Phone:970-485-3421
Mailing Address - Fax:970-453-1960
Practice Address - Street 1:106 N. FRENCH STREET
Practice Address - Street 2:SUITE 250
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424-4869
Practice Address - Country:US
Practice Address - Phone:970-485-3421
Practice Address - Fax:970-453-1960
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17635225100000X
CO0010078261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0010078OtherSTATE OF COLORADO LICENSE
MA11667806OtherCAQH
MA17635OtherP.T. LICENSE NUMBER
CO11667806OtherCAQH
MA17635OtherP.T. LICENSE NUMBER