Healthcare Provider Details

I. General information

NPI: 1124724513
Provider Name (Legal Business Name): SOULBRITE OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3472 SUNSHINE CANYON DR
BOULDER CO
80302-9722
US

IV. Provider business mailing address

3472 SUNSHINE CANYON DR
BOULDER CO
80302-9722
US

V. Phone/Fax

Practice location:
  • Phone: 267-980-9689
  • Fax:
Mailing address:
  • Phone: 267-980-9689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: COLLEEN MCCLOSKEY
Title or Position: OCCUPATIONAL THERAPIST
Credential: MOT
Phone: 267-980-9689