Provider Demographics
NPI:1013674795
Name:GRIBBEN, MADISON KATHERINE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:KATHERINE
Last Name:GRIBBEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SUMMER HAWK DR UNIT HH49
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-8810
Mailing Address - Country:US
Mailing Address - Phone:262-716-7178
Mailing Address - Fax:
Practice Address - Street 1:805 SUMMER HAWK DR UNIT HH49
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-8810
Practice Address - Country:US
Practice Address - Phone:262-716-7178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015087225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant