Provider Demographics
NPI:1679705206
Name:IIDA, CINDY N (MS, OT)
Entity Type:Individual
Prefix:MS
First Name:CINDY
Middle Name:N
Last Name:IIDA
Suffix:
Gender:F
Credentials:MS, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4953 SHADOW RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-8620
Mailing Address - Country:US
Mailing Address - Phone:303-809-2251
Mailing Address - Fax:
Practice Address - Street 1:4953 SHADOW RIDGE RD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8620
Practice Address - Country:US
Practice Address - Phone:303-809-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-15
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1202225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64750582Medicaid