Provider Demographics
NPI:1770527558
Name:OVERTON, BRENTFORD ALLEN (MSPT)
Entity type:Individual
Prefix:MR
First Name:BRENTFORD
Middle Name:ALLEN
Last Name:OVERTON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 N BAT MASTERSON LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1255
Mailing Address - Country:US
Mailing Address - Phone:719-320-6387
Mailing Address - Fax:
Practice Address - Street 1:1881 N BAT MASTERSON LN
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-1255
Practice Address - Country:US
Practice Address - Phone:719-320-6387
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist