Provider Demographics
NPI:1164854857
Name:BURGETT, ROSE (PT)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:BURGETT
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 1:4035 MOORHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5511
Mailing Address - Country:US
Mailing Address - Phone:678-416-9496
Mailing Address - Fax:678-364-7960
Practice Address - Street 1:4035 MOORHEAD AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5511
Practice Address - Country:US
Practice Address - Phone:678-416-9496
Practice Address - Fax:678-364-7960
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015431225100000X, 225100000X
GAPT011145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1164854857Medicaid