Healthcare Provider Details

I. General information

NPI: 1821844549
Provider Name (Legal Business Name): MARY PEZZELLA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 28TH ST
BOULDER CO
80301-1222
US

IV. Provider business mailing address

2706 28TH ST
BOULDER CO
80301-1222
US

V. Phone/Fax

Practice location:
  • Phone: 303-444-1290
  • Fax: 303-444-1837
Mailing address:
  • Phone: 303-444-1290
  • Fax: 303-444-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP027484T
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19904
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: