Healthcare Provider Details

I. General information

NPI: 1184814345
Provider Name (Legal Business Name): PROACTIVE PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N FALER AVE
PINEDALE WY
82941
US

IV. Provider business mailing address

PO BOX 1037
PINEDALE WY
82941-1037
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-6236
  • Fax: 307-367-3332
Mailing address:
  • Phone: 307-367-6236
  • Fax: 307-367-3332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN M HOLZ
Title or Position: OWNER PHYSICAL THERAPIST
Credential: DPT
Phone: 307-367-6236