Healthcare Provider Details

I. General information

NPI: 1275363020
Provider Name (Legal Business Name): EMILY L FULLER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 CENTER GREEN DR STE 110
BOULDER CO
80301-2364
US

IV. Provider business mailing address

PO BOX 5718
KALISPELL MT
59903-5718
US

V. Phone/Fax

Practice location:
  • Phone: 303-413-9903
  • Fax: 303-413-9907
Mailing address:
  • Phone: 406-756-0134
  • Fax: 406-300-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0019912
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: