Provider Demographics
NPI:1568863777
Name:WILLOUGHBY, BRANT MICHAEL (COTA)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:MICHAEL
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3634 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-7621
Mailing Address - Country:US
Mailing Address - Phone:785-201-4132
Mailing Address - Fax:
Practice Address - Street 1:1000 E STUART ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1555
Practice Address - Country:US
Practice Address - Phone:970-482-5712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000407224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0000407OtherSTATE OF COLORADO BOARD OF HEALING ARTS