Provider Demographics
NPI:1215208855
Name:PEDERSON, BARRY D M (OTR)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:D M
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 GRIFFIN PL
Mailing Address - Street 2:APT A
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1896
Mailing Address - Country:US
Mailing Address - Phone:303-579-0322
Mailing Address - Fax:
Practice Address - Street 1:601 GRIFFIN PL
Practice Address - Street 2:APT A
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-1896
Practice Address - Country:US
Practice Address - Phone:303-579-0322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3123225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist