Healthcare Provider Details

I. General information

NPI: 1376383604
Provider Name (Legal Business Name): BETHANY GRACE LASSEN OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 RESEARCH PKWY STE 205
COLORADO SPRINGS CO
80920-1093
US

IV. Provider business mailing address

2430 RESEARCH PKWY STE 205
COLORADO SPRINGS CO
80920-1093
US

V. Phone/Fax

Practice location:
  • Phone: 719-623-1795
  • Fax:
Mailing address:
  • Phone: 719-623-1795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT0008476
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: