Healthcare Provider Details

I. General information

NPI: 1891069308
Provider Name (Legal Business Name): TRACY STEWART THELEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 ARBOR WAY
COLORADO SPRINGS CO
80905-2128
US

IV. Provider business mailing address

1713 ARBOR WAY
COLORADO SPRINGS CO
80905-2128
US

V. Phone/Fax

Practice location:
  • Phone: 719-332-5868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number8379
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: