Provider Demographics
NPI:1831120641
Name:DOUGHTY, AMANDA BROE (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROE
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:BROE
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2430 RESEARCH PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1093
Mailing Address - Country:US
Mailing Address - Phone:719-623-1050
Mailing Address - Fax:719-623-1051
Practice Address - Street 1:4020 E PALMER PARK BLVD
Practice Address - Street 2:#101C
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-574-5234
Practice Address - Fax:719-574-8277
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0003883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO803715Medicare ID - Type Unspecified
Q55140Medicare UPIN