Provider Demographics
NPI:1215087648
Name:VICKLAND, PATRICIA (MA, PT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:VICKLAND
Suffix:
Gender:F
Credentials:MA, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 SUNSET ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3218
Mailing Address - Country:US
Mailing Address - Phone:303-776-0333
Mailing Address - Fax:303-776-0107
Practice Address - Street 1:1330 SUNSET ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3218
Practice Address - Country:US
Practice Address - Phone:303-776-0333
Practice Address - Fax:303-776-0107
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA193624OtherDEPT. OF LABOR - WASHINGT
CO4915543OtherCIGNA PIN#
COC481298Medicare PIN