Healthcare Provider Details

I. General information

NPI: 1780929448
Provider Name (Legal Business Name): VALERIE GAGAZA KENNEDY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 TENDERFOOT HILL RD
COLORADO SPRINGS CO
80906-3903
US

IV. Provider business mailing address

2309 STEPPING STONES WAY
COLORADO SPRINGS CO
80904-2756
US

V. Phone/Fax

Practice location:
  • Phone: 719-576-8380
  • Fax:
Mailing address:
  • Phone: 719-231-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0012431
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: