Provider Demographics
NPI:1982021465
Name:FORMICA, KATHLEEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:FORMICA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 TRAPPERS PL
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5955
Mailing Address - Country:US
Mailing Address - Phone:970-413-2390
Mailing Address - Fax:
Practice Address - Street 1:1000 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3914
Practice Address - Country:US
Practice Address - Phone:970-224-7025
Practice Address - Fax:970-224-7036
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00065502251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics