Healthcare Provider Details

I. General information

NPI: 1275047144
Provider Name (Legal Business Name): HEATHER LANE PHYSICAL THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S CHERRY ST STE 380
DENVER CO
80246-1230
US

IV. Provider business mailing address

425 S CHERRY ST STE 380
DENVER CO
80246-1230
US

V. Phone/Fax

Practice location:
  • Phone: 708-415-0827
  • Fax:
Mailing address:
  • Phone: 708-415-0827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0013308
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPTL.0013308
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICK H DONOVAN
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 720-507-3962