Provider Demographics
NPI:1922571793
Name:GOLDEN, MCKENZIE GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:GRACE
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:GRACE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1619 APACHE TRL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-2049
Mailing Address - Country:US
Mailing Address - Phone:719-684-6192
Mailing Address - Fax:
Practice Address - Street 1:917 E MORENO AVE STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4547
Practice Address - Country:US
Practice Address - Phone:719-623-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist