Provider Demographics
NPI:1407352123
Name:MONDRAGON, LYNN ELLEN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:ELLEN
Last Name:MONDRAGON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 EAGLERIDGE PL STE 140
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-4101
Mailing Address - Country:US
Mailing Address - Phone:719-253-7727
Mailing Address - Fax:719-253-7729
Practice Address - Street 1:4601 EAGLERIDGE PL STE 140
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-4101
Practice Address - Country:US
Practice Address - Phone:719-253-7727
Practice Address - Fax:719-253-7729
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0001038224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831338516OtherCLINIC NPI