Provider Demographics
NPI:1962982579
Name:FUSTOS, CAROL MARGARET (PT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:MARGARET
Last Name:FUSTOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:RATZLAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:309 S WHITCOMB ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2643
Mailing Address - Country:US
Mailing Address - Phone:719-924-4650
Mailing Address - Fax:
Practice Address - Street 1:1919 68TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8061
Practice Address - Country:US
Practice Address - Phone:970-350-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0002454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist