Provider Demographics
NPI:1699104919
Name:FEUTZ, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FEUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 WRIGHT ST
Mailing Address - Street 2:APT 208
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1405
Mailing Address - Country:US
Mailing Address - Phone:906-202-0846
Mailing Address - Fax:
Practice Address - Street 1:8301 E PRENTICE AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2903
Practice Address - Country:US
Practice Address - Phone:303-322-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0012443OtherMEDICARE