Healthcare Provider Details

I. General information

NPI: 1629699178
Provider Name (Legal Business Name): MANDI LYNN WADE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 RESEARCH PKWY STE 100
COLORADO SPRINGS CO
80920-1093
US

IV. Provider business mailing address

8101 E LOWRY BLVD STE 120
DENVER CO
80230-7195
US

V. Phone/Fax

Practice location:
  • Phone: 719-623-1050
  • Fax: 719-562-6225
Mailing address:
  • Phone: 720-865-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-008088
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0006861
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: