Healthcare Provider Details

I. General information

NPI: 1316282379
Provider Name (Legal Business Name): CARRIE ELIZABETH REAVIS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 E BAILS PL
DENVER CO
80222-4463
US

IV. Provider business mailing address

4580 E BAILS PL
DENVER CO
80222-4463
US

V. Phone/Fax

Practice location:
  • Phone: 970-219-2709
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2411
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: