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General NPI Number Information
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NPI Number | 1093147555
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Entity Type | Individual
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Provider Name | CARISSA MARIE WENGROVIUS P.T., D.P.T.
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Gender | Female
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Dates
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Enumeration Date | 08/06/2013
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Last Update Date | 08/06/2013
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Provider Practice Location Address
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Address Line | 801 MAIN ST STE 10
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City | LOUISVILLE
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State | CO
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Zip | 80027-1898
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Country | US
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Telephone | 303-604-6441
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Fax |
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Provider Business Mailing Address
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Address Line | 9538 CASTLE RIDGE CIR
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City | HIGHLANDS RANCH
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State | CO
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Zip | 80129-5701
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Country | US
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Telephone | 303-859-9459
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 0012318
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License Number State | CO
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