Healthcare Provider Details

I. General information

NPI: 1831451517
Provider Name (Legal Business Name): EVA KATHLEEN ELLISON MSOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EVA KATHLEEN TWEEDY

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 N UNION BLVD
COLORADO SPRINGS CO
80918-1744
US

IV. Provider business mailing address

111 CRYSTAL PARK RD UNIT 1
MANITOU SPRINGS CO
80829-2652
US

V. Phone/Fax

Practice location:
  • Phone: 719-434-7044
  • Fax: 719-375-1276
Mailing address:
  • Phone: 512-788-3762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0003655
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number114685
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: