Healthcare Provider Details

I. General information

NPI: 1942766076
Provider Name (Legal Business Name): KELLY MARIE GREGG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 ARAPAHOE RD
BOULDER CO
80303-1407
US

IV. Provider business mailing address

4285 MILLIKEN CT
BOULDER CO
80303-2532
US

V. Phone/Fax

Practice location:
  • Phone: 970-232-0237
  • Fax:
Mailing address:
  • Phone: 970-232-0237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number023083
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT.0006908
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: