Provider Demographics
NPI:1902006513
Name:DECIANNE, PRISCILLA THERESE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:THERESE
Last Name:DECIANNE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5713 REED ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-2645
Mailing Address - Country:US
Mailing Address - Phone:303-463-5864
Mailing Address - Fax:
Practice Address - Street 1:5713 REED ST
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-2645
Practice Address - Country:US
Practice Address - Phone:303-463-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-21
Last Update Date:2007-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7868225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52287041Medicaid