Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PTL. 0013479 | CO |
NPI | 1033596747 |
---|---|
Provider Name | Autumn Grove |
First Address | Lakewood, CO 80215 |
Second Address | Lakewood, CO 80215 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2015 |
Last Update Date | 04/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PTL. 0013479 | COLORADO STATE PHYSICAL THERAPY LICENSE (01) | CO |