Healthcare Provider Details

I. General information

NPI: 1629900980
Provider Name (Legal Business Name): MIA GRACE NEADERHISER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 MEDICAL CENTER PT STE 180
COLORADO SPRINGS CO
80907-5798
US

IV. Provider business mailing address

12317 W 101ST ST
LENEXA KS
66215-1909
US

V. Phone/Fax

Practice location:
  • Phone: 719-344-9497
  • Fax:
Mailing address:
  • Phone: 913-579-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0021316
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: