Provider Demographics
NPI:1720339054
Name:BEMIS, BROOKE ELIN (DPT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIN
Last Name:BEMIS
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 1:1262 BERGEN PKWY UNIT E10
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9546
Mailing Address - Country:US
Mailing Address - Phone:303-674-7889
Mailing Address - Fax:
Practice Address - Street 1:1262 BERGEN PKWY UNIT E10
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439
Practice Address - Country:US
Practice Address - Phone:303-674-7889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013169225100000X
IDPT-3019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1720339054Medicaid
WAG8917517Medicare UPIN