Provider Demographics
NPI:1245688480
Name:GRANDBOUCHE, CARLIE LORRAYNE (DPT)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:LORRAYNE
Last Name:GRANDBOUCHE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 S UNIVERSITY BLVD
Mailing Address - Street 2:#140
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-5065
Mailing Address - Country:US
Mailing Address - Phone:303-471-4506
Mailing Address - Fax:
Practice Address - Street 1:9330 S UNIVERSITY BLVD
Practice Address - Street 2:#140
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-5065
Practice Address - Country:US
Practice Address - Phone:303-471-4506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist