Provider Demographics
NPI:1962159772
Name:BETTLE, MAXWELL LEWIS (PTA)
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:LEWIS
Last Name:BETTLE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 RIMROCK DR
Mailing Address - Street 2:
Mailing Address - City:SILT
Mailing Address - State:CO
Mailing Address - Zip Code:81652-8101
Mailing Address - Country:US
Mailing Address - Phone:970-366-1924
Mailing Address - Fax:
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-2941
Practice Address - Country:US
Practice Address - Phone:970-625-0842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant