Healthcare Provider Details

I. General information

NPI: 1386821825
Provider Name (Legal Business Name): RED WILLOW OCCUPATIONAL MYOFASCIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 S PERRY ST SUITE 260
CASTLE ROCK CO
80104-1900
US

IV. Provider business mailing address

823 S PERRY ST SUITE 260
CASTLE ROCK CO
80104-1900
US

V. Phone/Fax

Practice location:
  • Phone: 303-902-8476
  • Fax: 303-265-9515
Mailing address:
  • Phone: 303-902-8476
  • Fax: 303-265-9515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JULIANN HANSON-ZLATEV
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR
Phone: 303-902-8476