Basic Information
| Provider Information | |||||||||
| NPI: | 1912177593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMONE | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 WESTERN AVE | ||||||||
| Address2: | SUITE B | ||||||||
| 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: | 03/10/2008 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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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 | 2251S0007X | PTL.0002327 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 225100000X | PTL.0002327 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 97273805 | 05 | CO | MEDICAID |