Provider Demographics
NPI:1073737755
Name:FYFFE, MICHAEL J E (OTR)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J E
Last Name:FYFFE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:COLORADO
Other - Middle Name:OCCUPATIONAL AND
Other - Last Name:LYMPHEDEMA THERAPY LLC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2624 ESPINOZA ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-3913
Mailing Address - Country:US
Mailing Address - Phone:419-508-3996
Mailing Address - Fax:
Practice Address - Street 1:2624 ESPINOZA ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3913
Practice Address - Country:US
Practice Address - Phone:419-508-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT6357225X00000X
COOT.0002493225X00000X
NM2329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000142280Medicaid
CO5477805ZXUNMedicare PIN