Provider Demographics
NPI:1922871771
Name:HIESTAND, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:HIESTAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2857 SHADOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4730 TABLE MESA DR STE K100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5591
Practice Address - Country:US
Practice Address - Phone:303-954-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist