Provider Demographics
NPI:1942541313
Name:MICK, CYNTHIA (PTA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:MICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10125 W DARTMOUTH PL
Mailing Address - Street 2:#104
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-6721
Mailing Address - Country:US
Mailing Address - Phone:906-235-6127
Mailing Address - Fax:
Practice Address - Street 1:10125 W DARTMOUTH PL
Practice Address - Street 2:#104
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-6721
Practice Address - Country:US
Practice Address - Phone:906-235-6127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012997225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0012997OtherMEDICARE