Provider Demographics
NPI:1740786250
Name:BEVERLIN, SANDRA R (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:BEVERLIN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:R
Other - Last Name:BEVERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:18406 W WHITE QUEST DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84013-9701
Mailing Address - Country:US
Mailing Address - Phone:303-840-6374
Mailing Address - Fax:303-374-8290
Practice Address - Street 1:18406 W WHITE QUEST DR
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84013-9701
Practice Address - Country:US
Practice Address - Phone:217-891-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0005359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1740786250Medicaid