Basic Information
Provider Information | |||||||||
NPI: | 1326195710 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TORRENCE | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, ATC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALFORD | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5450 WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803012709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033159900 | ||||||||
FaxNumber: | 3033159902 | ||||||||
Practice Location | |||||||||
Address1: | 2150 STADIUM DR | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803090001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033159900 | ||||||||
FaxNumber: | 3033159902 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2007 | ||||||||
LastUpdateDate: | 11/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | PTL.0006257 | CO | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2255A2300X | AT.0000716 | CO | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PTL.0006257 | CO | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 07062573 | 05 | CO |   | MEDICAID |