Healthcare Provider Details

I. General information

NPI: 1154323624
Provider Name (Legal Business Name): GABRIEL D ETTENSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2005
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 FRANKLIN ST
NIWOT CO
80544-5013
US

IV. Provider business mailing address

5624 COTTONTAIL DR
LONGMONT CO
80503-9529
US

V. Phone/Fax

Practice location:
  • Phone: 516-967-8108
  • Fax: 516-967-8108
Mailing address:
  • Phone: 516-967-8108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0012163
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: