Provider Demographics
NPI:1033625645
Name:KLINK, LEETTA RAE (OTA)
Entity Type:Individual
Prefix:
First Name:LEETTA
Middle Name:RAE
Last Name:KLINK
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7898 BLACK WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-2207
Mailing Address - Country:US
Mailing Address - Phone:415-425-3804
Mailing Address - Fax:
Practice Address - Street 1:5446 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3644
Practice Address - Country:US
Practice Address - Phone:719-598-5555
Practice Address - Fax:719-388-2030
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000951224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty