Provider Demographics
NPI:1568847580
Name:COLORADO OCCUPATIONAL THERAPY
Entity Type:Organization
Organization Name:COLORADO OCCUPATIONAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KORENSTRA METZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSOTR,L
Authorized Official - Phone:616-635-1720
Mailing Address - Street 1:PO BOX 5033
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-5033
Mailing Address - Country:US
Mailing Address - Phone:616-635-1720
Mailing Address - Fax:
Practice Address - Street 1:34520 HIGHWAY 6 #C17
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-5033
Practice Address - Country:US
Practice Address - Phone:616-635-1720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003354251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94007861Medicaid