Basic Information
Provider Information
NPI: 1003000829
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KOCHANEK
FirstName: MICHELLE
MiddleName: RENEE
NamePrefix:  
NameSuffix:  
Credential: PT, DPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: GARTNER
OtherFirstName: MICHELLE
OtherMiddleName: RENEE
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: PT, DPT
OtherLastNameType: 1
Mailing Information
Address1: 1325 S COLORADO BLVD STE 206
Address2:  
City: DENVER
State: CO
PostalCode: 802223311
CountryCode: US
TelephoneNumber: 3033943356
FaxNumber:  
Practice Location
Address1: 1325 S COLORADO BLVD STE 206
Address2:  
City: DENVER
State: CO
PostalCode: 802223311
CountryCode: US
TelephoneNumber: 3033943356
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/05/2007
LastUpdateDate: 11/01/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPTL.0012104COY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X070015931ILN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
745407701 AETNAOTHER
0162233301 BLUE CROSS BLUE SHIELD IDOTHER


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