Basic Information
| Provider Information | |||||||||
| NPI: | 1831451517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | EVA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | MSOT, OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TWEEDY | ||||||||
| OtherFirstName: | EVA | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 CRYSTAL PARK RD | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | MANITOU SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808292652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127883762 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5775 N UNION BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809181744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194347044 | ||||||||
| FaxNumber: | 7193751276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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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 | 225X00000X | OT.0003655 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 114685 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.