Basic Information
| Provider Information | |||||||||
| NPI: | 1831120641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHTY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | BROE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARROLL | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | BROE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2430 RESEARCH PKWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809201093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196231050 | ||||||||
| FaxNumber: | 7196231051 | ||||||||
| Practice Location | |||||||||
| Address1: | 4020 E PALMER PARK BLVD | ||||||||
| Address2: | #101C | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195745234 | ||||||||
| FaxNumber: | 7195748277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTL.0003883 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.