MEDICARE: CARLY RIANNE VAN TINE OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT.0007117	CO

General Provider Information

NPI Number	:	1568129955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY RIANNE VAN TINE OTR/L

Provider Business Mailing Address
First Line	:	706 ROCKY MOUNTAIN WAY
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2615
Country	:	US
Telephone Number	:	970-290-0216
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 E PROSPECT RD STE 200
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5304
Country	:	US
Telephone Number	:	970-495-8454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2021
Last Update Date	:	02/04/2026

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