MEDICARE: AMY ELIZABETH MEDLOCK PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTL.0014900	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PTL.0014900	OTHER	CO	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1619515954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY ELIZABETH MEDLOCK PT, DPT

Provider Business Mailing Address
First Line	:	8362 E BRIARWOOD BLVD
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-1319
Country	:	US
Telephone Number	:	720-334-5870
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 W MINERAL AVE STE 116A
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80120-4510
Country	:	US
Telephone Number	:	303-798-5602
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2019
Last Update Date	:	12/17/2019

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