Provider Demographics
NPI:1841351178
Name:MERRILL, CHARLIE (PT)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:MERRILL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 GOLD RUN RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1790 30TH ST
Practice Address - Street 2:SUITE 314
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1022
Practice Address - Country:US
Practice Address - Phone:303-444-8707
Practice Address - Fax:303-444-8109
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QP2000X CO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7010OtherPT LICENSE NUMBER