Provider Demographics
NPI:1356167670
Name:CENTENO, MARANDA L (MSOT)
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:L
Last Name:CENTENO
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-300-1612
Practice Address - Street 1:3425 AUSTIN BLUFFS PKWY STE 105
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5723
Practice Address - Country:US
Practice Address - Phone:719-912-2110
Practice Address - Fax:719-400-6413
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0008659225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist