Provider Demographics
NPI:1891579066
Name:DETWILER, COLTEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:COLTEN
Middle Name:
Last Name:DETWILER
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 1:10320 W MCDOWELL RD STE 1447
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-4879
Mailing Address - Country:US
Mailing Address - Phone:623-907-4400
Mailing Address - Fax:
Practice Address - Street 1:10320 W MCDOWELL RD STE 1447
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4879
Practice Address - Country:US
Practice Address - Phone:623-907-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33192225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist