Provider Demographics
NPI:1649785452
Name:PETSCHKE, KAITLIN R
Entity type:Individual
Prefix:MS
First Name:KAITLIN
Middle Name:R
Last Name:PETSCHKE
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 1:451 21ST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1421
Mailing Address - Country:US
Mailing Address - Phone:303-678-7170
Mailing Address - Fax:
Practice Address - Street 1:451 21ST AVE STE A
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1421
Practice Address - Country:US
Practice Address - Phone:303-678-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20986225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist