Healthcare Provider Details

I. General information

NPI: 1205100906
Provider Name (Legal Business Name): MIA C BEVERIDGE MSOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 AUSTIN BLUFFS PKWY STE 105
COLORADO SPRINGS CO
80918-5723
US

IV. Provider business mailing address

PO BOX 5718
KALISPELL MT
59903-5718
US

V. Phone/Fax

Practice location:
  • Phone: 719-912-2110
  • Fax: 719-400-6413
Mailing address:
  • Phone: 406-756-0134
  • Fax: 406-300-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT.0004267
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0004267
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: