Provider Demographics
NPI:1992937759
Name:CONNOLLY, CHARLES MATHEW (PTA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MATHEW
Last Name:CONNOLLY
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 1:10703 MOORE WAY
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3629
Mailing Address - Country:US
Mailing Address - Phone:303-464-1152
Mailing Address - Fax:
Practice Address - Street 1:9160 W 64TH AVE
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-3111
Practice Address - Country:US
Practice Address - Phone:303-420-7258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-0616225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant