Provider Demographics
NPI:1114453198
Name:STORM, CORALIE (COTA)
Entity Type:Individual
Prefix:
First Name:CORALIE
Middle Name:
Last Name:STORM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 SCARBOROUGH DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7513
Mailing Address - Country:US
Mailing Address - Phone:719-630-7500
Mailing Address - Fax:
Practice Address - Street 1:8540 SCARBOROUGH DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7513
Practice Address - Country:US
Practice Address - Phone:719-630-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000912224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COOTA.0000912Medicare PIN