Healthcare Provider Details

I. General information

NPI: 1831055219
Provider Name (Legal Business Name): MACKENZIE SUE RAE WHITESIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 STADIUM DRIVE 2ND FLOOR
BOULDER CO
80309-0001
US

IV. Provider business mailing address

6491 CRESTBROOK DR
MORRISON CO
80465-2230
US

V. Phone/Fax

Practice location:
  • Phone: 303-315-9900
  • Fax: 303-315-9902
Mailing address:
  • Phone: 303-642-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0021024
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: