Provider Demographics
NPI:1831451517
Name:ELLISON, EVA KATHLEEN (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:KATHLEEN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:KATHLEEN
Other - Last Name:TWEEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 CRYSTAL PARK RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-2652
Mailing Address - Country:US
Mailing Address - Phone:512-788-3762
Mailing Address - Fax:
Practice Address - Street 1:5775 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1744
Practice Address - Country:US
Practice Address - Phone:719-434-7044
Practice Address - Fax:719-375-1276
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0003655225X00000X
TX114685225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist