Basic Information
| Provider Information | |||||||||
| NPI: | 1033625645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLINK | ||||||||
| FirstName: | LEETTA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | OTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7898 BLACK WALNUT DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809202207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154253804 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5446 N ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195985555 | ||||||||
| FaxNumber: | 7193882030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2017 | ||||||||
| LastUpdateDate: | 12/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 0000951 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.