Provider Demographics
NPI:1215084892
Name:GAMM, SUSAN GRACE (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GRACE
Last Name:GAMM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 29TH ST
Mailing Address - Street 2:STE 102
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2358
Mailing Address - Country:US
Mailing Address - Phone:303-601-7495
Mailing Address - Fax:888-433-8309
Practice Address - Street 1:777 29TH ST
Practice Address - Street 2:STE 102
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2358
Practice Address - Country:US
Practice Address - Phone:303-601-7495
Practice Address - Fax:888-433-8309
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06-6600Medicare Oscar/Certification