Provider Demographics
NPI:1083985295
Name:MALCOLM, MATT (PHD, OTR)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:PHD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-1974
Mailing Address - Country:US
Mailing Address - Phone:970-420-6448
Mailing Address - Fax:
Practice Address - Street 1:1309 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-1974
Practice Address - Country:US
Practice Address - Phone:970-420-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2619225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist