Provider Demographics
NPI:1184878308
Name:FUNCTIONAL PHYSICAL THERAPY, LLC, A COLORADO PROFESSIONAL COMPANY
Entity type:Organization
Organization Name:FUNCTIONAL PHYSICAL THERAPY, LLC, A COLORADO PROFESSIONAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:GALE HACKETT
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, CFMT, FMTF
Authorized Official - Phone:970-846-3300
Mailing Address - Street 1:2800 KALMIA AVE APT C318
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1590
Mailing Address - Country:US
Mailing Address - Phone:970-846-3300
Mailing Address - Fax:
Practice Address - Street 1:1412 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-2617
Practice Address - Country:US
Practice Address - Phone:970-846-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6843261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy