Provider Demographics
NPI:1801198288
Name:MARIE, QIYRA (MPT)
Entity Type:Individual
Prefix:
First Name:QIYRA
Middle Name:
Last Name:MARIE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:MARIE
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:PO BOX 2613
Mailing Address - Street 2:428 STICKNEY AVE
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-2613
Mailing Address - Country:US
Mailing Address - Phone:303-823-5325
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:303-579-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist