Healthcare Provider Details

I. General information

NPI: 1710478045
Provider Name (Legal Business Name): BROOK TYLER STEPHENS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SPRUCE CT
DURANGO CO
81301-7213
US

IV. Provider business mailing address

23 SPRUCE CT
DURANGO CO
81301-7213
US

V. Phone/Fax

Practice location:
  • Phone: 719-722-7806
  • Fax:
Mailing address:
  • Phone: 719-722-7806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0015630
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: