MEDICARE: MISS AMY LYNN LATENDRESSE GLASER 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	0009869	CO

General Provider Information

NPI Number	:	1861517781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMY LYNN LATENDRESSE GLASER DPT

Provider Business Mailing Address
First Line	:	115 E HARMONY RD
Second Line	:	STE. 115
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3280
Country	:	US
Telephone Number	:	970-221-1201
Fax Number	:	800-675-0273

Provider Business Practice Location Address
First Line	:	115 E HARMONY RD
Second Line	:	STE 115
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3280
Country	:	US
Telephone Number	:	970-221-1201
Fax Number	:	800-675-0273

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	03/17/2017

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