Provider Demographics
NPI:1104888619
Name:TICHY-SMITH, AMY S (MPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:TICHY-SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:TICHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:3206 MAIN AVE UNIT 5
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4202
Mailing Address - Country:US
Mailing Address - Phone:970-247-9632
Mailing Address - Fax:970-247-9642
Practice Address - Street 1:3206 MAIN AVE UNIT 5
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4202
Practice Address - Country:US
Practice Address - Phone:970-247-9632
Practice Address - Fax:970-247-9642
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52430324Medicaid
CO52430324Medicaid
COC543258Medicare PIN