Provider Demographics
NPI:1902991920
Name:DECRAENE, EDITH E (PT)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:E
Last Name:DECRAENE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 EVERGREEN PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2942 EVERGREEN PKWY
Practice Address - Street 2:STE 100
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7909
Practice Address - Country:US
Practice Address - Phone:303-670-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC800629Medicare PIN