Basic Information
| Provider Information | |||||||||
| NPI: | 1861971996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGETT | ||||||||
| FirstName: | SARA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7340 S ALTON WAY | ||||||||
| Address2: | STE 11-D | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801122323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204931181 | ||||||||
| FaxNumber: | 7204931191 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 WILLARD ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021691274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177700022 | ||||||||
| FaxNumber: | 6174711114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 16559 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 110138832A | 05 | MA | MEDICAID |