Healthcare Provider Details

I. General information

NPI: 1205373602
Provider Name (Legal Business Name): MARY FAUSSETT MOTR/L, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 ARISTA PL
BROOMFIELD CO
80021-4154
US

IV. Provider business mailing address

2026 JUNIPER WAY
ERIE CO
80516-7966
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-9188
  • Fax:
Mailing address:
  • Phone: 720-273-7532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberOT.0001533
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: