Provider Demographics
NPI:1801576269
Name:SELEY, SIDNEY NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:NICOLE
Last Name:SELEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 E PALMER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1741
Mailing Address - Country:US
Mailing Address - Phone:719-569-0732
Mailing Address - Fax:
Practice Address - Street 1:4601 EAGLERIDGE PL STE 140
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-4101
Practice Address - Country:US
Practice Address - Phone:719-253-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0001707224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty