Healthcare Provider Details

I. General information

NPI: 1871653089
Provider Name (Legal Business Name): SUSAN LIVINGSTON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 EAST SOUTH STREET
BAYFIELD CO
81122
US

IV. Provider business mailing address

PO BOX 966
BAYFIELD CO
81122-0966
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-3259
  • Fax: 970-884-2842
Mailing address:
  • Phone: 970-884-3259
  • Fax: 970-884-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberNBCOT#208009
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: