Healthcare Provider Details

I. General information

NPI: 1295273696
Provider Name (Legal Business Name): GEORGIA PAULS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6450 MAROON MESA DR
COLORADO SPRINGS CO
80918-6103
US

IV. Provider business mailing address

6450 MAROON MESA DRIVE
COLORADO SPRINGS CO
80918
US

V. Phone/Fax

Practice location:
  • Phone: 719-592-9205
  • Fax:
Mailing address:
  • Phone: 719-592-9205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number12372
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: