Basic Information
| Provider Information | |||||||||
| NPI: | 1164993168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRITT | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7622 MCLAUGHLIN RD | ||||||||
| Address2: | |||||||||
| City: | PEYTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808314710 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7622 MCLAUGHLIN RD | ||||||||
| Address2: | |||||||||
| City: | PEYTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808314710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194953133 | ||||||||
| FaxNumber: | 7194958685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PTL.0015193 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | PTL.0015193 | 05 | CO | MEDICAID |