Provider Demographics
NPI:1790772630
Name:HARRISON, MITZI L (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:MITZI
Middle Name:L
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:L
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:675 SNOWBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7365
Mailing Address - Country:US
Mailing Address - Phone:720-829-2564
Mailing Address - Fax:720-204-1748
Practice Address - Street 1:1800 30TH ST STE 206
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1026
Practice Address - Country:US
Practice Address - Phone:720-845-0001
Practice Address - Fax:720-204-1748
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO132192251H1200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT15363OtherPHYSICAL THERAPY LICENSE
CAPT15363OtherPHYSICAL THERAPY LICENSE